Rider Application
*Riders must be between 6 - 18 years of age at the time of riding sessions.

**Applications for the next upcoming sessions will remain open until our application deadline has past. After the deadline has passed, our board will review all applications. A letter will be mailed to you a couple weeks prior to the first session if the applicant will or will not be accepted into the program**

Website: reinsofhopespencer.org
Contact Us: reinsofhopespencer@gmail.com
Contact: Stephanie Mesner at (712) 229-6558
Riders Name *
Parents Name *
Address
Telephone Number: Day (Format: 123-456-7890) *
Telephone Number: Evening (Format: 123-456-7890)
Email Address *
Date of Birth *
MM
/
DD
/
YYYY
Diagnosis *
Impairments: *
Required
Please provide any specifics that may aid our understanding of the applying Riders condition.
Are braces or other assistive devices used?
Clear selection
Medical history you think is pertinent: (ie. seizures, breathing trouble)
Riders Height
Riders Weight
Riders T-Shirt Size
**Due to the number of applicants, should your rider not be chosen to participate, would you be willing to be placed on a wait list? This means you would agree to be contacted should a scheduled rider not be available for a session. All applicable forms must be completed to participate.
Clear selection
***Once the application deadline has passed and our review process has been completed by our board members, we will notify you of your riders participation status. This is typically a few weeks prior to the start of the next Session. Thank you!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy