One on One Session Request Form

"*" indicates required fields

Contact Name*

First Last

Child's Name

Child's Gender

Child's Date of Birth

Guardian or Sponsor Name

First Last

Participant Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Cell Phone*

Contact Email*

First Requested Date*

Date must be at least 25-days in advance

2nd Choice requested Date

3rd Choice requested Date*

If none of your requested dates are available would you like to be automatically added to a wait list?

What days of the week generally work best for you?*

How did you find out about us?*

Have you ever participated in a program with any of the following organizations?*

Have you previously been enrolled in a one-on-one session at Mandalay Farms?*

Which program are you interested in?*

Therapeutic Riding

Equine Therapy

Sensory Petting Zoo

No preference; Please let facilitator choose best fit and availability

Describe your reason for applying for a session and what you hope to gain from the session. Please be as detailed as possible.*

Please list any physical challenges we should be aware of that may help us in providing a good experience*