GallopNYC prospective Hippotherapy rider form

Please use this form to express interest in Hippotherapy at GallopNYC.

If you are interested in another program, please check our website at Programs 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 over 18)

Title

First Name

Last Name

Address:

Street

City

State

Zip Code

Phone

Company

Rider Information

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Please enter date as MM/DD/YYYY

Weight (lb)

Primary Diagnosis

Secondary Diagnosis (if applicable)

Any Additional Information Relevant to Diagnosis

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

Mobility Status

Ambulatory? Assistive Device?

Ethnic Background

Contact Information