Participant Information
Attention: For Hippotherapy, there is a WAITLIST. The only way to get on the waitlist is by completion of this form. Thank you for understanding. There is less wait time for Adaptive Riding. For more info on the differences between Hippotherapy and Adaptive Riding, visit /
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Email *
Name of Person Completing this Form *
Relationship to Participant *
Last Name *
Birth Date *
Gender *
TEXT Capable Phone *
(required for receiving notice about cancellations due to weather)
Alternate Phone *
Street Address *
City/State/ZIP *
County of Residence *
School or Day Program *
Receive Therapy Home-based or Outpatient?
Referral Source *
Primary Health Insurance Name and Policy # *
Secondary Insurance Information
Insurance Guarantor's Name and Date of Birth *
Waiver (CES/SLS)
Case Management Agency
Case Manager
Case Manager Phone
Case Manager Email
Which service(s) are you seeking for the participant? *
Note about the provision of horse-mounted activities or therapies
The provision of horse-mounted activities is conditional, based on combined factors of participant weight and height, horses' physical capacity, and the availability of volunteer side-walkers, among other variables. Eligibility for participation is determined by individual instructors or therapists who are responsible for assessment and participant safety. 
Session time is dependent on the client's abilities, endurance, and overall tolerance to this activity.  Adaptive Riding and Hippotherapy sessions generally include "off horse" time, such as grooming, tacking, and walking the horse. Sessions do not always include full "on horse" time, as the instructor or therapist determines the best treatment for each session. Part of the activity for the day may include exercises or stretching.
Participant's Height and Weight *
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