Therapeutic Riding Wait List Form
Lovelane is a therapeutic horseback riding program that has a dramatic impact on the social, cognitive and physical development of children with an array of special needs. Therapeutic horseback riding focuses on achieving wide-ranging therapeutic goals in a unique and motivating setting. Lovelane is primarily a PEDIATRIC FACILITY, serving children from age 2-20. The length of the time your child is on the wait list is entirely dependent on their availability and the open lesson times Lovelane has on our schedule. After you submit this form, Lovelane will be in touch if we have an opening that matches your availability. We also will be in touch via email to offer other opportunities for wait list students throughout the year.
Email address *
STUDENT INFORMATION
Student Last Name *
Student First Name *
Student Date of Birth *
MM
/
DD
/
YYYY
Gender *
Student Height *
x' x"
Student Weight *
xx lbs
School & Grade *
Student Primary Diagnosis & Disability *
Student Vision & Hearing Level, Please Select One: *
None
Partial
Good
Vision
Hearing
Student Information, please select YES or NO *
YES
NO
Can sit independently
Can walk independently
Uses a wheelchair
Understands verbal directions
Communicates with sign language
Has ridden a horse before
Previous experience with horses or riding *
Behavioral issues Lovelane should be aware of *
Relevant allergies (animals, dust, hay, etc) *
Home Address *
# & Street
City & State *
Zip Code *
AVAILABILITY (DAYS)- Please check off all days your child is available to ride: *
Required
AVAILABILITY (TIMES): Please be as SPECIFIC as possible with any time options for the days your child is available. Lovelane holds lessons daily between 9:00am and 6:00pm. *
Example: M, W, F between 2:15 and 6:00 OR Thurs between 9:00 and 12:00
I would like to add my child to the wait list for: *
please check all that apply
Required
I am interested in having my child participate in the following other opportunities available to students while they are on the wait list waiting for a spot in the core riding program and/or Barn Buddies: *
please check all that apply
Required
Notes:
Any additional information that would be helpful for us to know
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