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 complete 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.

When a class time becomes available, an on-site evaluation will be scheduled. The initial evaluation fee will be due at that time. After the assessment, the Center will recommend a program and class best suited for the client.

 *= 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.