RideAbility Student Application Form Date:___________
This form indicates your interest in being a student rider in the RideAbility program – it does not necessarily
enroll you in a riding class or guarantee class availability for you. The sooner this form is filled out and
returned the more likely it will be that there will be a class space open for you to ride. (RideAbility is
served on a first-come-first-serve basis, with consideration for our ability to provide the needs for each
individual applicant and their family.) When class schedules are set, and volunteers are committed,
RideAbility will contact you to confirm your class dates and times.
Please complete a separate form for each rider, and return forms to:
RideAbility P.O. Box 995 Pine Island, MN 55963
{Online forms may be emailed to rideability@[Link]}
RIDER’S NAME ________________________________________________________________________
ADDRESS _____________________________________________________________________________
CITY ______________________________________________ STATE _______ ZIP CODE ____________
TELEPHONE NUMBER (Day) _________________________ (Evening) ___________________________
Email:__________________________________________________________________________________
PARENT or
GUARDIAN(s)_______________________________________________PHONE:____________________
Rider’s Profile:
DATE OF BIRTH (MM/DD/YY): _____/_____/_____ HEIGHT __________ WEIGHT ______lbs
DISABILITY (or none)____________________________________________________________________
Does this rider use a cane?____leg braces?____walker?____wheelchair?_____other aids?_______________
Please describe any range of motion limitations with hips/knees/ankles:______________________________
_______________________________________________________________________________________
Do you anticipate any problems sitting on the horse, or any extra help/support that might be needed?______
_______________________________________________________________________________________
Can this rider grasp reins?______ saddle horn?_______ other hand holds?____________________________
Can this rider walk up 3 steps to get on the mounting block?______with help?_______on their own?______
Has this rider ever had seizures?________ If yes, please explain extent, duration, frequency:_____________
_______________________________________________________________________________________
Is this rider presently medicated? __________ Any breakthrough seizures? ___________________________
Is this rider verbal?____non-verbal?____sign language?____ Please describe communication skills in more
detail (ie. Shy, over-active, deaf, hearing impaired, hugs a lot, etc.)__________________________________
_______________________________________________________________________________________
Does this rider have specific fears, behavior issues or other problems that we should be aware of?_________
_______________________________________________________________________________________
BRIEFLY DESCRIBE WHY STUDENT WANTS TO PARTICIPATE IN RIDEABILITY: (For example:
for fun, for a family activity, general social interaction, to learn about horses, for physical benefits like
balance/coordination/stamina, or further reasons …….) __________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
Please indicate what dates and times your family would like to schedule their riding classes:
Class session/dates(Spring, May&June, July&August, Fall):__________________________________________________
Day of the week(Monday, Tuesday, other): ___________________________________________________________
Time(6:30PM, 7:30PM, other):_____________________________________________________________________
RideAbility will do their best to accommodate family needs in class scheduling
