GREENLOCK TRC COURSE REGISTRATION FORM

Name:__________________________________________________________________

Address: Street_______________________________________________________

City_______________________ State __________ Zip ___________

Home Phone:_____________________________ Work Phone:___________________

Email Address:_________________________________________________________

Horsemanship skills: _________________________________________________

Height: _____________________ Weight: _________________________

Profession: PT _________ OT _________ SLP ________ Other______________

Indicate Years of Experience in each:

Pediatrics:______ Rehabilitation:______ Therapeutic Riding:______

Hippotherapy:______ Manual Therapy:______ Other:______

What do you hope to accomplish at this course? _____________________

_______________________________________________________________________

Proof of Level l Courses (# attached): ____ Certificate copy of Equine

Level l (or Equine Level 1 waiver form) & Treatment Principles Level l

Arriving by: Auto:_____ Plane:_____ Airline:__________________________

Flight #: _________ Day: ___________________ Time: ______________

Lunch is included each day. Vegetarian please _________

Checks to be made payable to:

Greenlock Therapeutic Riding Center, Inc.

___ Level 1 Equine Skills $325.00 May 1-2, 2008

___ Level 1 Treatment Principles $325.00 May 2-4, 2009

___ Level 2 Equine Skills $350.00 Nov. 6-7, 2008

___ Level 2 Treatment Principles $350.00 Nov. 7-9, 2008

Please send this form, along with your check or money order to:

Greenlock Therapeutic Riding Center, Inc.

55 Summer Street

Rehoboth, MA 02769

Telephone: (508) 252-5814