Rider Application

Fill this out to join the Cooper's Calling waitlist. Requested schedule times aren't guaranteed — we'll contact you to schedule an in-person evaluation.

Rider first name Rider last name Date of birth Address

Home phone

Mobile phone

Parent/Guardian 1

Name

Phone

Occupation

Parent/Guardian 2 (optional)

Name

Phone

Occupation

Rider Information

Disabilities Other therapies

Height

Weight

Student goals Physician name, address, and phone number Schedule preference

Enrollment Acknowledgment

I would like to enroll the above rider at Cooper's Calling and have discussed this with the rider's doctor. Instruction will be under strict supervision, and although every effort will be made to avoid any accident, no liability can be accepted by Cooper's Calling or any persons involved (employees or volunteers).

Type your full name as your signature

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