Rider Application
*Riders must be between 6 - 18 years of age at the time of riding sessions.
**Due to the number of applicants, 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 or

Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address
Your answer
Telephone Number: Day (Format: 123-456-7890)
Your answer
Telephone Number: Evening (Format: 123-456-7890)
Your answer
Diagnosis
Your answer
Parents Name
Your answer
Email Address
Your answer
Please indicate which session(s) you are applying for: *
Required
Impairments: *
Required
Are braces or other assistive devices used?
Medical history you think is pertinent: (ie. seizures, breathing trouble)
Your answer
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