Thank you for your interest in the J.F. Shea Therapeutic Riding Center. We are eager to help you become a part of the program!

Please completely fill out the form below. This form and all private information you provide, is kept strictly confidential and never released without your consent. You will be contacted by phone, letter or email within 5 business days of receipt. Email is the fastest method so please include yours.

An initial on-site evaluation will be scheduled when a class time becomes available. A one time evaluation fee is due at time of initial evaluation. After the evaluation, the Center will recommend a class best suited to you.

Note - new facilities and increased staffing allow us to offer more classes although they may not occur at the most popular times of the day or week.

 *= Required Fields
Name of Participant:*
Parent/Guardian First Name (if applicable):
Parent/Guardian Last Name (if applicable):

E-mail Address:*
(Parent/Guardian if applicable)
Address:*
City:*
State:*
Zip Code:*
Home Phone:*
Cell Phone:*
Emergency Contact First Name:*
Last Name:*
Relationship:*
Phone:*
Participant Date of Birth:* MM/DD/YYYY
Gender:*
Diagnosis:*
Date of Onset:* YYYY
Father Occupation:
Mother Occupation:
Past Health History:
Recent Changes in Health History:
Current Medications:
Precautions/Restrictions:
How Were You Referred to the Center:
Any Questions:
I understand that additional release forms and documentation will require my attention after this form is submitted to continue enrollment with The Shea Center.