2019 Therapeutic Class Registration Form

Rider name *
Rider name
Date of birth *
Date of birth
VARHA has a policy of 180 pound limit for all riders.
Address *
Phone number *
Phone number
Parent/guardian phone
Parent/guardian phone
Class(es) Requested. Please be aware that you may not get the time you request, but we will do our best to accommodate your schedule.
Fall session - September 3 through October 24 - Cost $240
Fall Tuesdays
Please mark preferred time ** 6 PM CLASS IS FULL **
Fall Thursdays
Please mark preferred time
Payment information
Payment Method *
Full Payment is due by the 1st day of class. This section MUST be filled out in order for us to process your application! Leaving it blank will delay your registration.
If paying privately, please leave blank.
Agency address
Agency address
If paying privately, please leave blank.
Private Pay Options
We accept Visa & MasterCard payments.
A limited amount of scholarship money is available for income eligible clients.
If you would like to apply for scholarship money, please check here and send copies of income statements with application.
Digital signature
Digital Signature of Parent/guardian
Date form was completed. *
Date form was completed.