Annual Participant Update Form – Flying Manes Therapeutic Riding

Participant Information

Please complete the form below. The information helps us to provide safe and effective lessons to your child.

Participant Name *

First

Last

Date of Birth *//

Weight (lbs) *

Height (feet, inches) *

Primary/Secondary Diagnosis *

First Parent/Guardian Name *

First

Last

Email *

Phone *

Second Parent/Guardian Name *

First

Last

Email *

Phone *

Primary Care Physician Name *

First

Last

Phone *

Current allergies, medications, and health concerns /recent surgeries or medical developments: *

Participant's current ambulatory status, posture, balance, movement, coordination: *

Does participant receive physical therapy? *

Does participant receive occupational therapy? *

Does participant have an IEP? *

Recent developments in/ current level of participant's cognitive abilities (age level, multi-step directions): *

Recent developments in/ current status of participant's general attitude & behavior: *

Participant's communication style and challenges/ recent developments: *

What are the participant's goals for this year's riding sessions (riding skills, behavioral changes, physical improvements, paying attention)? Please be specific: *

Please note any limitations for lesson start/end times or scheduling conflicts you may have:

Are there any special considerations you would like us to keep in mind?

Do you have any other suggestions or comments for us?

Name