Wheatland Equestrian Online Registration

Registration

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Welcome to Wheatland Farm! New students are REQUIRED to complete the following registration form. Please be SURE to fill out this form THOROUGHLY, including information about past riding experience, disabilities, health concerns or learning disabilities.

* denotes required fields

Referral Information

How did you hear about us?*

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Info (Not Contact #1 or #2)*

Health Insurance Carrier

Contact #1

Contact #1 First Name*

Last Name *

Type*

How Can We Contact You?

Home Phone

Work #

Cell # *

By providing your phone number and checking this box, you agree to receive transactional and informational SMS messages from Wheatland Equestrian. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for help.

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Contact #2 First Name

Last Name

Type

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Rider Gender*

Birth Date*

Cell #* By providing your phone number and checking this box, you agree to receive transactional and informational SMS messages from Wheatland Equestrian. Message frequency may vary. Message and data rates may apply. Reply STOP to opt out and HELP for help.

Additional Info

Rider Email*

T-Shirt Size

School

Grade Level

Transportation

Disabilities (PLEASE be thorough!) If none, write NONE*

Special health or behavior concerns. If none, write NONE*

Allergies

Medications (List all)

Primary Doctor

Photography? YES or NO*

Previous riding experience?*

Please tell us about student*

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Rider Gender*

Birth Date*

Additional Info

Rider Email*

T-Shirt Size

School

Grade Level

Transportation

Disabilities (PLEASE be thorough!) If none, write NONE*

Special health or behavior concerns. If none, write NONE*

Allergies

Medications (List all)

Primary Doctor

Photography? YES or NO*

Previous riding experience?*

Please tell us about student*

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Rider Gender*

Birth Date*

Additional Info

Rider Email*

T-Shirt Size

School

Grade Level

Transportation

Disabilities (PLEASE be thorough!) If none, write NONE*

Special health or behavior concerns. If none, write NONE*

Allergies

Medications (List all)

Primary Doctor

Photography? YES or NO*

Previous riding experience?*

Please tell us about student*

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Rider Gender*

Birth Date*

Additional Info

Rider Email*

T-Shirt Size

School

Grade Level

Transportation

Disabilities (PLEASE be thorough!) If none, write NONE*

Special health or behavior concerns. If none, write NONE*

Allergies

Medications (List all)

Primary Doctor

Photography? YES or NO*

Previous riding experience?*

Please tell us about student*

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Rider Gender*

Birth Date*

Additional Info

Rider Email*

T-Shirt Size

School

Grade Level

Transportation

Disabilities (PLEASE be thorough!) If none, write NONE*

Special health or behavior concerns. If none, write NONE*

Allergies

Medications (List all)

Primary Doctor

Photography? YES or NO*

Previous riding experience?*

Please tell us about student*

Add Another Student

Required Policies

(Show-Hide Details)

Questions or Concerns

Comments

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies

(Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Student #2 (Show-Hide Details)

Additional Info

Student #3 (Show-Hide Details)

Additional Info

Student #4 (Show-Hide Details)

Additional Info

Student #5 (Show-Hide Details)

Additional Info

Required Policies (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Required Policies

(Show-Hide Details)