Client Application - Hippotherapy
Thank you for your interest in Hippotherapy at Miracles in Motion. Please complete this application. In addition, your therapist will provide you with our General Liability, Photo Release, and Medical Form tthat need to be completed. Please have participant's referring medical professional complete and sign.
Email address *
Participant First Name *
Participant Last Name *
Mailing Address *
City *
State *
Zip Code *
County *
Participant School Attending *
Participant Grade or Level Completed (if applicable) *
Primary Parent/Legal Guardian/Caregiver First Name *
Primary Parent/Legal Guardian/Caregiver Last Name *
Relationship to Participant *
Primary Parent/Legal Guardian/Caregiver Phone Number *
Primary Parent/Legal Guardian/Caregiver Email *
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