Therapeutic Riding Registration- Winter 2026

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EEMV Participant Registration for Therapeutic Riding- Winter Semester 2026 (January 19th- February 19th)

Parent or Caretaker Name (if applicable)

Participant Name *

Participant Date of Birth *

YYYY

Participant Primary Diagnosis *

Participant Secondary Diagnosis (if applicable)

Phone Number *

Email *

Participant Height *

Participant Weight *

Have you participated with our program before? *

**If you have not participated at EE before, please complete this form and then contact Dayna at dayna@eemv.org or 6363-390-2141 to get our Participant Registration Packet

Yes

No**

If new, how did you hear about us?

Please select the times/days you are available- Select AT LEAST 3 that are possibilities for you-

**Please note, we have limited availability this semester due to staffing. We will resume Friday and Saturday sessions in March**

Monday mornings

Monday afternoons

Monday evenings

Tuesday mornings

Tuesdays afternoons

Tuesday evenings

Wednesday mornings

Wednesday afternoons

Thursday mornings

Thursday afternoons

Thursday evenings

I would like to participate but none of these options work for our family

Required

Any scheduling notes? ( ie. I am only available after 5, etc)

Client Goals (short term and long term) *

Best way to contact me:

Phone

Text

Clear selection

I'd like to make my payments (please note, weekly payments are not an option)

In full at the beginning of the semester

In monthly payments

I need to set up a different payment plan- please contact me

Clear selection

I'd like to request a financial assistance application

Yes

Clear selection

If you are a returning client, have there been any changes to your contact information or medical information since your last full paperwork? This includes changes to height/weight, diagnosis, contact information, etc.

No- All the information is the same since our last paperwork

Yes- there have been changes since our last completed paperwork

Clear selection

I have read the form and attest that all the information provided is accurate *

Yes

Submit

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