Name:_________________________________________ Today Date:____________________________

Birthday:__________________

 

Address:_______________________________________________________________________________

______________________________________________________________________________________

 

Parentsí Name(s):________________________________________________________________________

 

Phone:___________________________ Cell:_______________________ Work:___________________

 

Email:________________________________________________________________________________

 

Contact in case of emergency: __________________________________ Phone:_________________

 

Doctor: _________________________________ Phone:____________________________________

 

Hospital: ________________________________________________________________________

 

Allergies: ______________________________________________________________________________________

______________________________________________________________________________________

Level of Riding: (please circle)

Beginner Intermediate Beginner Intermediate Advanced Intermediate Advanced

 

Number of Years Riding:____________________ Type/Style:____________________________________

 

Special Instructions:

______________________________________________________________________________________

______________________________________________________________________________________

Goaled from Lessons:

______________________________________________________________________________________

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