EMERALD HOLLOW THERAPEUTIC RIDING CENTER, INC.                                                                          PARTICIPANT QUESTIONNAIRE

It is helpful for the staff at Emerald Hollow Therapeutic Riding Center, Inc. to know what your (or your child’s) participation goals and interests are, and to understand your (or your child’s) current status prior to developing a program for you (or your child). Please complete the following questions:                

 Participant’s Name: __________________________________________________ DOB: _________________                                                                 

 Please indicate the program(s) you are interested in: Riding _________ Equine Learning _________                                                                                    Availability: Day(s): __________________________________ Times: _____________________________                                                                        Diagnosis: ________________________________________________________________________________                                                                     Posture: __________________________________________________________________________________                                                                  Balance: __________________________________________________________________________________                                                                Movement / Coordination: ____________________________________________________________________ __________________________________________________________________________________________                                                                  General Attitude & Behavior: _________________________________________________________________                                                                 Perceptual / Balance Problems: ________________________________________________________________                                                    Communication Challenges & Methods (Verbal, Sign, PEC): ________________________________________ __________________________________________________________________________________________                                                                Cognitive Abilities (age level, multi step directions) ________________________________________________ __________________________________________________________________________________________                                                                      What are your goals for the riding sessions (i.e., riding skills, behavioral changes, physical improvements, paying attention). Please be specific ____________________________________________________________ __________________________________________________________________________________________                                                                          Are there any special considerations that EHTRC should be aware of? (i.e., health precautions, medications, etc.) ______________________________________________________________________________________ __________________________________________________________________________________________                                                                Describe any previous horseback riding experience ________________________________________________ __________________________________________________________________________________________                                                                      Areas of interest, games & activities enjoyed _____________________________________________________ __________________________________________________________________________________________                                                                    Please note that Emerald Hollow Therapeutic Riding Center, Inc. may require additional documentation of medical conditions and a clearance from your health care provider.

Signature: ____________________________________________________ Date: ______________________ Participant/Parent/Legal Guardian