Name:_________________________________________ Today Date:____________________________

Birthday:__________________

Address:_______________________________________________________________________________

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Parents’ 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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