Participant Enquiry

Participant enquiry

Name of person completing form *

Relationship to participant (e.g. self, parent, support coordinator etc.) *

Email address *

Phone number *

Participant first name *

Participant last name

Please select Equilus Centre/s suitable to your location *

Jennibrook Farm - WoodcroftMount GambierNorthern Area - Globe Derby ParkO'Halloran HillOakbankPort LincolnPort PirieSouthern Fleurieu - Victor HarborYorke Peninsula - Kadina

What type of program are you interested in? *

Mounted program (horse riding)Unmounted or supported volunteering programCarriage drivingSchool or community group

Please select the participant weight range. This is needed to so we can provide you information about programs to suit you. Each of our centres has weight limit relative to the horses available. Some centres may not be able to accommodate riders over 80kg. Weight limits do not apply to unmounted programs. *

20-4 kg40-60 kg60-80 kg80-100 kg100+ kg

Participant age *

3-67-1213-1718+

Participant disability / diagnosis? Please select all that apply. *

AutismIntellectual DisabilityPhysical DisabilityCerebral PalsyDowns SyndromeVision ImpairmentHearing ImpairmentABI / TBIOther

What days and times are you available to participate in a program? Note: Your preferred Centre may not operate or offer programs 7 days a week. *

Monday AMMonday PMTuesday AMTuesday PMWednesday AMWednesday PMThursday AMThursday PMFriday AMFriday PMSaturday AMSaturday PM

Is there anything else that you would like us to know at this initial enquiry stage?

I have taken a moment to read the Equilus Funding Information document. *

I have read and understood the Equilus Privacy Collection Notice. *

Today's date *

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