Therapeutic Riding Lessons Registration Form
Email address *
Bright Star Equestrian Centre: 13922 State Highway 97, Petersburg, IL
Applicant's Name: *
Your answer
Gender *
Date of Birth *
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YYYY
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
County *
Your answer
Ethnicity *
We ask this in order to provide data for some of our grant funding partners. You may choose "prefer not to answer" if you prefer.
Required
Parent/Guardian's Name (If over 18, type in your information.) *
Your answer
Parent/Guardian's Employer (If over 18, type in your information.) *
Your answer
Parent/Guardian's Job Title (If over 18, type in your information.)
Your answer
Parent/Guardian's Work Phone (If over 18, type in your information.) *
Your answer
Parent/Guardian's Cell Phone (If over 18, type in your information.) *
Your answer
Parent/Guardian's Preferred Method of Contact (If over 18, select your preferred method.) *
Other Parent/Guardian's Name:
Your answer
Other Parent/Guardian's Employer
Your answer
Other Parent/Guardian's Job Title
Your answer
Other Parent/Guardian's Work Phone
Your answer
Other Parent/Guardian's Cell Phone
Your answer
Other Parent/Guardian's Email Address
Your answer
Rider's Physician *
Your answer
Physician's Phone Number *
Your answer
Rider's Therapist
Indicate Physical, Occupational, Speech, or "Other"
Your answer
Rider's Therapist's Phone Number
Your answer
Have you attended Bright Star before? *
If a new client, how did you hear about us? *
Applicant's Current Residence *
If applicant lives in a group home or other specialized facility, please provide address and phone number.
Your answer
Which day is rider most available for lessons? *
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