Clone of 2026 SESSION REGISTRATION FORM

2026 SESSION REGISTRATION
Participant Name

First NameLast Name
Birthdate

MonthDayYear
Date
Age
Parent or Caregiver Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Participant Diagnosis (Brief)
Equine Assisted Services

Please Select ALL Times That Could Work for Participant to Come Once Weekly. Note that Occupational Therapy (OT) is 40-minute appointment.

Rows	TUESDAY	THURSDAY
10:00-10:40AM Occupational Therapy 1:1
11:20-12:00 PM Occupational Therapy 1:1
12:00-12:40 PM Occupational Therapy 1:1
12:40-1:20 PM Occupational Therapy 1:1
1:20-2:00 PM Occupational Therapy 1:1
2:40-3:20 PM Occupational Therapy 1:1
3:20-4:00 PM Occupational Therapy 1:1
4:00-4:40 PM Occupational Therapy 1:1

For Therapeutic Riding (TR) and Equine-Assisted Learning (EAL), PRIVATE AND GROUP classes are 45 minutes on Wednesday. Select all possible times that may fit your schedule.

Rows	WEDNESDAY
12:30-1:15PM Therapeutic Riding
1:45-2:30PM Therepautic Riding
3:00-3:45 PM Therapeutic Riding/EAL
4:15-5:00 PM Therapeutic Riding
5:30-6:15 PM Therapeutic Riding
6:45-7:30 PM Therapeutic Riding

For Therapeutic Riding (TR) and Equine-Assisted Learning (EAL), GROUP classes are 45 minute classes on Saturday. Select all possible dates and times that may fit your schedule.

Rows	SATURDAY
10:00 AM Therapeutic Riding
11:15 AM Therapeutic Riding

Please Write PREFERRED Day/Time to Come Once Weekly (PROGRAM DIRECTOR / INSTRUCTOR will determine appropriate class or therapy.)
Please Share Participant GOALS :: Hope to Improve/Experience in 6-week Session
I understand that the $75/appointment or class payment for entire session (i.e.$450 for six weeks) is due March 1, 2026; May 1, 2026; Aug 1, 2026 and Oct 10, 2026. A reminder will be sent out. Therapy fees are in addition to the $75/hr and are payable to the therapist. If RoG cancels, a makeup time will be offered. If Participant cancels, no makeup will be offered and no reduction of fee offered. Failure to notify RoG in advance of horse prep and volunteer arrival may adversely impact future participation in light of wait list of riders that wish to participate.

Parent/Caregiver Signature Required
Date

MonthDayYear
Date
Paperwork Expiration

MonthDayYear
Date

PAYMENT
How will you pay the session fee?
Payment for session fees may be made by check as long as the check is received by the due date (March 1, 2026; May 1, 2026; Aug 1, 2026 and Oct 10, 2026).

Send checks to:

Rhythms of Grace

23625 River Heights Dr

Dallas Center, IA 50063
NOTE: PAYMENT OF PROCESSING FEES IS REQUIRED IF PAYING ONLINE.

Session Fee

SIX-WEEK SESSION FEE

Checks may be mailed for session fees as long as they are received by due date. NOTE PAYMENT OF PROCESSING FEES IS REQUIRED IF PAYING ONLINE.

$450.00

Total

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Campaign ID
Amount Due
Session Timing
Should be Empty:

2026 SESSION REGISTRATION

PAYMENT

Session Fee*

Session Fee