2017 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 *
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.
Preseason Tuesdays - March 28 through April 25, 6:00 PM-7:00 PM - Cost $137.50
Limited to the first 5 applicants. Indicate if interested in signing up.
Spring session - May 9 through June 29 - Cost $220
The 6 PM sessions fill quickly, you may request to be added to the cancelation list.
Spring Tuesdays **CLASS IS FULL**
Please mark preferred time.
Spring Thursdays
Please mark preferred time
Summer session - July 11 through August 31 - Cost $220
Summer Tuesdays **CLASS IS FULL**
Please mark preferred time
Summer Thursdays
Please mark preferred time
Fall session - September 5 through October 26 - Cost $220
Fall Tuesdays **CLASS IS FULL**
Please mark preferred time
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.
Scholarships
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.