GallopNYC Prospective Rider Form

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Please use this form to express interest in the therapeutic riding program at GallopNYC.

If you are interested in another program, please follow this link for more information:




If you are unsure, or would like more information, please contact us or call 855) 925-5661
Parent Information (or Rider Information if the rider is an adult)













Rider Information



Please enter date as MM/DD/YYYY




EX: verbal/nonverbal, uncontrolled seizures, social, etc.

Ambulatory? Assistive Device?









First + Last Name

Please add any information you would like to share with us
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Contact Information