EmailMe Form - Equine Therapy Registration

Child Attending *

First Last

Age of Child *

Additional Child Attending

First Last

Age of child

List any additional children attending and their ages

Does the child have any known allergies? *

Yes

No

Please specify

Emergency Contact Name *

First Last

Emergency Contact Phone Number *

### - ### - ####

Email *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Reason for attending Equine Therapy (list your child's recent grief related experience) *