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 *
Your answer
Participant Last Name *
Your answer
Mailing Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
County *
Your answer
Participant School Attending *
Your answer
Participant Grade or Level Completed (if applicable) *
Your answer
Primary Parent/Legal Guardian/Caregiver First Name *
Your answer
Primary Parent/Legal Guardian/Caregiver Last Name *
Your answer
Relationship to Participant *
Your answer
Primary Parent/Legal Guardian/Caregiver Phone Number *
Your answer
Primary Parent/Legal Guardian/Caregiver Email *
Your answer
Next
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service