Rider Information Form

Please submit the following, or if you prefer, download the .pdf form, print and mail to:
Northland Therapeutic Riding Center
P.O. Box 1267
Kearney, MO 64060


Rider's Application and Health History
(To be completed by the rider or parent/legal guardian.)

Rider's Name:

DOB: Age: Height: Weight: Sex: M F

Rider's Address:

City: State: Zip: County:

Phone - Preferred #: Would you like to be notified by Text: Yes No

Phone - Alternative #: Would you like to be notified by Text: Yes No

Email:

Rider's Employer or School Name (if applicable):


Address: Phone:

Name of Parent/Legal Guardian (if participant is under 18 years of age):


Parent/Legal Guardian Address/Phone (if different from rider's address above):

Address:

City: State: Zip:

Phone - Preferred #: Text: Yes No

Phone - Alternate #: Text: Yes No

Email:

Name of Personal Assistant if applicable:


Phone #: Email:

Please indicate current or past difficulties in the following systems/areas:

Vision
Yes No Comments:
Sensation
Yes No Comments:
Breathing
Yes No Comments:
Communication
Yes No Comments:
Hearing
Yes No Comments:
Digestion
Yes No Comments:
Elimination
Yes No Comments:
Heart
Yes No Comments:
Circulation
Yes No Comments:
Emotional
Yes No Comments:
Behavioral
Yes No Comments:
Pain
Yes No Comments:
Bone/Joint
Yes No Comments:
Muscular
Yes No Comments:
Thinking/Cognition
Yes No Comments:
Allergies
Yes No Comments:
Application
Yes No Comments:

What medications are you currently taking, including over-the-counter medications?


Describe your abilities/difficulties in the following areas (including assistance required or equipment needed):

FUNCTION (i.e. Mobility skills such as transfers, walking, wheelchair use, driving/bus riding)


SOCIAL (i.e. Work/school including grade completed, leisure interests, relationships-family structure, support systems, companion animals, fears/concerns, etc.)


GOALS (i.e. What would you like to accomplish through your participation in a therapeutic riding program?)


Signature of Rider or Parent/Legal Guardian:

Date:

Physician Information Form

Participant's Medical History and Physician's Statement
(To be completed by physician.)

CLICK HERE TO DOWNLOAD PHYSICIAN INFORMATION FORM.






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