*
*
*
*
*
*
*
*
*
*
*
*
Rider Application Form
Date of Birth (Month/Day/Year)
*
How did you hear about CARD?
Reason for application to CARD program
Equipment needs
Equipment Client uses in daily life (please check all that apply)
None
Orthotics/AFOs/Braces
Walker
Stander
Wheelchair
Adapted seating
Communication aids
Other splints
Other (Please elaborate below)
Equipment (if other than options above)
Areas of concern
Areas of concern (please check all that apply)
Range of motion/flexibility
Strength
Mobility
Balance
Motor planning
Spatial/body awareness
Coordination
Sensory behaviour
Physical fitness
Social skills
Communication
Other (please elaborate below)
Areas of concern (if other than options above)
Other relevant information/comments:
Diagnosis:
Diagnosis
*
Strategies for Success:
Please share if the applicant responds to a particular approach or personality type, i.e. quiet demeanors, highly animated interaction, etc.
Additional Information: Please indicate if any of the following are relevant to the applicant, as they can be safety issues in a riding environment depending on how and when they are expressed. We will reach out to you for further details to understand your/your child's specific needs.
*
Hitting
Biting
Screaming and/or loud vocalizations
Elopement
Difficulty with direction following
Unable to sit without back support
Weight above 73Kg (160Lbs)
None of the above
Date of Birth (Month/Day/Year)
How did you hear about CARD?
Reason for application to CARD program
Equipment needs
Equipment Client uses in daily life (please check all that apply)
Equipment (if other than options above)
Areas of concern
Areas of concern (please check all that apply)
Areas of concern (if other than options above)
Other relevant information/comments:
Diagnosis:
Diagnosis
Strategies for Success:
Please share if the applicant responds to a particular approach or personality type, i.e. quiet demeanors, highly animated interaction, etc.
Additional Information: Please indicate if any of the following are relevant to the applicant, as they can be safety issues in a riding environment depending on how and when they are expressed. We will reach out to you for further details to understand your/your child's specific needs.
Powered by Sumac Nonprofit CRM Software
version 7.4.17.2
