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SPIRIT HORSE MEDICINE Application, please fill in all blanks

Name: ________________________________________________________

Address: ______________________________________________________

City: ______________________ State: ____________ Zip: ____________

Phone: Day ________________ Evening: _____________________

E-mail: _____________________________ Fax: _____________________

I give permission to have this contact information shared in the group.  Yes___  No ___

Emergency contact name: ____________________ Phone: _______________

Briefly describe what draws you to this workshop (relationships, career, health, spirituality, grief or loss, personal growth, etc)__________________________

I understand that I am attending an experiential workshop where I will be working with horses as teachers to discover information about myself that I can apply to my life.
My support system includes: Spiritual Practice Group____, Individual/Group Therapy____,
12 Step Program____, Family and Friends_____, Coach____, Other____

Please note that this is an Equine Experiential Learning Workshop and is not appropriate for people with serious active mental health issues.

Please describe any special needs or issues, such as diet, disabilities, and fear of horses act. that the staff should know about to better serve you:

Briefly describe your experience with horses (equine experience not necessary):

I am applying for the following event:

Please mail a check (made out to Spirit Horse Medicine, LLC) and registration to:

Spirit Horse Medicine, LLC
Jennifer Grais 638 B
220 N. Zapata Hwy #11
Laredo, TX 78043-4464