FRANCAIS
Rider Application
Child Information
First name :
Last name :
Height (inches) :
Weight (pounds) :
Shoe size :
Age :
Date of birth :
Sex :
Language :
Languages spoken :
Please separate each language by a comma
Address (line 1) :
Address (line 2) :
City :
Province :
Postal code :
Format: X9X 9X9
Phone number (1) :
Format: 999-999-9999
Phone number (2) :
Format: 999-999-9999
Medicare number :
Format: XXXX 9999 9999
Medicare expiry date :
Session requested :
Child's Behavior
Please indicate any behaviors that might be challenging for Epona staff to deal with.
Parent Information
First name :
Last name :
Phone number (1) :
Format: 999-999-9999
Phone number (2) :
Format: 999-999-9999
E-mail address :
Format: example@domain.com
Physician Information
First name :
Last name :
Phone number :
Format: 999-999-9999
E-mail address :
Format: example@domain.com
Medical Information
Will you child need to take medication while with us…If YES please expalin?
Does your child have any medical conditions? (Including any type of allergy) and what is the treatment?
Emergency Contact Information
First name :
Last name :
Phone number (1) :
Format: 999-999-9999
Phone number (2) :
Format: 999-999-9999
E-mail address :
Format: example@domain.com
Comments
Administration fee of $25.00 must be included with this application. All areas of this form must be filled in.