Rider Referral/Request

Application to participate in an RDA programme.

Request/Referral made by:
Referrer/requester name*
Organisation name
Complete only if application is being made on behalf of an organisation.
Position in Organisation
Email*
Phone*
Rider Information
This information is required to enable the RDA Group to consider whether they are able to accept the prospective Rider into their RDA programme. All information supplied will be considered confidential, and stored and used in accordance with the Privacy Act 1993.
Name of Rider*
First Last
Main Contact Phone*
Main Contact Email*
Rider Address*
Street Address Address Line 2 City ZIP / Postal Code New Zealand
Age of Rider*
Date of Birth*
DD slash MM slash YYYY
Height of Rider*
Expressed in m. Do NOT include "m"
Weight of Rider*
Expressed in kg. Do NOT include "kg"
We have a maximum rider weight of 75kgs. Enrolments will NOT be considered over this.
Ethnicity of Rider*
- New Zealand/European
- Maori
- Pasifika
- Asian
- Other
Required for statistical purposes only.
Diagnosis*
Other information (eg assessment info)
Rider or Legal Guardian to complete this section
Name of person completing*
First Last
I understand that;
- This information is required to enable the RDA Group to consider suitability to participate in an RDA programme.
- If accepted, further medical or educational information can be supplied for safety and planning purposes.
- Final acceptance will be at the discretion of the RDA Group, after consultation with other relevant people where necessary, and that referral does not guarantee entrance into a riding programme.
Consent*
I agree to this referral/request
Applicant agrees that the information provided is accurate at the time of application and agrees to the terms above.

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Rider Referral/Request

Rider Referral/Request

Request/Referral made by:

Rider Information

Rider or Legal Guardian to complete this section

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Rider Referral/Request

Rider Referral/Request

Request/Referral made by:

Rider Information

Rider or Legal Guardian to complete this section

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