Participant Registration

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will a caregiver attend the program with you?

Yes

No

May we contact your employer regarding becoming a business sponsor?

Yes

No

What led you to apply for Operation Horses and Heroes? *

Check all that apply

Friend/Family Recommendation

Veteran Service Org ( VFW, Am Vet)

Internet Site

Medical Recommendation

Love of Horses

FaceBook

VA Medical Facility

Military

Personal Choice

Other

What is your experience with horses? *

None

Beginner

Medium

Expert

Fear

What challenges do you deal with heading into this program? *

Check all that apply

Bad Dreams

Memories

Flashbacks

Relationships

Easily Startled

Emotionally Numb

Sleeping Problems

Anger

Irritability

Hopelessness

Depression

Suicidal Thoughts

Headaches

Stomach Pains

Muscle Aches

Back Pain

Avoiding Places

Shaking

Loss of Interest

Panic Attacks

Alcoholism

Drug Addiction

Homelessness

Addictions

Other

Do you have any dietary restrictions?

Vegetarian

Gluten Free

Diabetic

Lactose Free (non-dairy)

Religious

Sulfite Free

Organic

Low Sodium

Allergies

Do you have any special requirements pertaining to the following?

Wheelchair Access

Prosthetics

Hearing

Speech

Other