Online In-take Form Please answer all of the questions below to share your rider profile. ← BackThank you for your response. ✨ Thank you for your submission. Abby will respond as soon as possible. —Ride On! Rider Name [First and Last)(required) Email(required) Date of Birth (MM/DD/YYYY) Must be 18 years or older, or accompanied by legal guardian.(required) Do you have a medical diagnosis for a physical or cognitive disability? If yes please explain?(required) If you responded no to the previous question but still believe that you qualify for this resource please explain why in the blank below? How will you pay for this service? (EX: IRIS funding, DVR, or Private Pay)(required) If you’re using IRIS or DVR, please state who your IC (IRIS Consultant) is or your DVR Counselor and provide their email: Do you give us permission to contact them to discuss funding? Do you require/ or use a physical support such as a cane, walker, crutch, wheelchair, or other automated device?(required) Will you be riding alone or with care giver assistance? If you are riding with a caregiver, respite provider, family friend, service animal etc. What is the name of your riding companion?(required) What is your level of proficiency in the English language? (Intermediate, fluent, or none.) Do you require a translator? If so what is your native language?(required) Is the individual filling out this form the person receiving this training?(required) Is there anything else you would like to let Abby know about? SubmitSubmitting form Δ Share this: Share on X (Opens in new window) X Share on Facebook (Opens in new window) Facebook Like this:Like Loading...
