New Client Registration Form

Please complete and submit the form below

The first step to receiving services at RISE Rehab is to fill out our Client Registration Form. Once your registration form has been received, you will receive an email inviting you to establish your Client Portal account.

It’s our hope that all prospective clients, eligible to participate in the program, will begin as soon as possible. Acceptance depends on availability of volunteers, horses, safety precautions and contraindications. Waiting lists are utilized when the program is at capacity.

Client Full Name

Client Date of Birth

Client Gender

Client Diagnosis

Client Weight

Client Height

Client School / Employer

Parent / Legal Guardian Full Name

Parent / Legal Guardian Cell Phone

Parent / Legal Guardian Email

Street Address

City

State

Zip Code

Emergency Contact

Emergency Phone

Additional Information

* information is required

New Client Registration Form

THANK YOU FOR YOUR SUPPORT