Application and Photo Release
Name: ____________________________________________________
DOB: ___ / ___ /___ Age: _____ Height: _____ Weight: _____ Male / Female
Ethnicity______________
Address: _________________________________________________County________
Home Phone: _____________________ Cell phone: __________________________
Preferred phone:_____________________________________
Email Address: _________________________________________________________
Employer/School: ________________________________________________________________
Address: _____________________________________ Phone: ________________
Parent/Legal Guardian: _________________________ Phone: _________________
Address (if different from above): ________________________________________________________________
Referral Source:
How did you hear about the program? Client Service Provider ____ Website _____
Social Media ___ Event On Site _____ Event Off Site _____ Friend _____
What medications are you currently taking, including over-the-counter medications? _________________________________________________________________
List Allergies; ________________________________________________________
Describe your abilities/difficulties in the following areas (include assistance required or equipment needed):
Experience with horses___________________________________________
___________________________________________________________
Experience with special needs_________________________________________
_________________________________________________________________
Goals: _______________________________________________________
Why are you applying for participation?
Therapeutic Riding _____ Extended Hours _______ Ranch Experience _______
Recreational Riding _____ Volunteering _________
Photo Release
I _____ Do I _____ Do Not
Consent to and authorize the use and reproduction by Prospect Riding Center of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.
Signature: ____________________________________________________ Date: _________
Parent / Legal Guardian/Participant if over 18