New Rider Application

Rider Sessions First Name: Last Name: Email: Home Phone: Phone 2: Home Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Riders First Name Riders Last Name Riders Birth Date Riders Age Disability or Diagnosis Any Limitations? Riding Experience. Weight under 30 lbs Between 30 and 50 Lbs Over 50 lbs Over 100 lbs 100 - 150lbs 150 - 160 lbs 160 - 170 lbs 170 - 180 lbs 180 - 190 lbs 200 lbs Over 200 lbs Any Food Allergies? Down Syndrome Diagnosis Yes No Negative Cervical X-Ray for Down Syndrome Diagnosis Yes No Other Therapies Mobility: Can rider walk on own? Do they need assistance sitting? Wheelchair? Please describe rider's mobility Is rider able to express themselves verbally? Yes No Has rider been diagnosised with Epilepsy? Yes No What are some positive re-enforcers rider likes?Praise, high-five, thumbs up? Describe rider's attention span? Any visual limitations? Yes No Any hearing limitations? Yes No Any Speech limitations No Non-verbal Delayed Speech Selective Mutism Other What are rider's favorite hobbies/interests? What goals would you like to see rider accomplish while riding with Silver Lining Riding?