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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:

to submit this application and proceed to payment.

Thank you, Spirit Horse Medicine, LLC