Adaptive Services Intake Form

Type of Adaptive Service You Are Interested In

Therapeutic Riding
Horses Helping Hoosier Heroes (Veterans)

Please select which adaptive service you are inquiring about.

Preferred Agape Location*

Agape North - Cicero, IN (Veterans programming currently NOT available at Agape North)
Agape South - Martinsville, IN
Agape East - Greenfield, IN

Agape North is located at 24970 Mt. Pleasant Road in Cicero, IN.
Agape South is located at 5070 SR 67 N in Martinsville, IN.
Agape East is located at 531 W. 100 S. in Greenfield, IN.

Prospective Participant Information

Prospective Participant Name*

First Last

Birthdate

Please enter the date of birth for the prospective rider. Minimum age is 4 years old.

Age

Please enter a number from 4 to 100.

Gender*

Female
Male

Special Need/Diagnosis

Parent/Guardian Contact Information

Parent/Guardian Name*

First Last

Contact Email*

Enter Email Confirm Email

Preferred Phone Number

How do you prefer that we follow up with you?

Email
Phone

How did you hear about us?*

If you were referred by someone, please tell us who we can thank.

Anything else you would like us to know?

Comments

This field is for validation purposes and should be left unchanged.

Adaptive Services Inquiry

Prospective Participant Information

Parent/Guardian Contact Information

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