Registration for Therapeutic Riding

Please provide the following contact information:

Rider's Name-First Last

Parent/Guardian Name-First Last

Street Address

Address (cont.)

City

State

Zip Code

Work Phone

Home Phone

Cell phone

E-mail

Session preference-first choice

Session preference-second choice

Please contact me by

Comments or questions

For more information call 248 634-7276

Thank you.
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Revised: 12/25/07