TRAK Registration Form 2023

Medical Information

Insurance information is required
Hospital/Clinic Preference
Physician's Name*
Physician's Phone Number*

Area CodePhone Number
Insurance Company*
You MUST have Insurance to participate
Policy Number*
You MUST have Insurance to participate
Allergies

NutsGlutenCaseinSoyLactose intoleranceHay/Seasonal/EnvironmentalOther
Allergies (any details you wish to add)
Does your child take medication? If so, what, and how often? Do any of the medications impact balance or judgment?*
Write N/A if not applicable to your registration.
Are there any behavioral patterns or concerns we should know about?*
Anything else that we should know about you or your child?
What goals do you have for your child?*
For Minor Child:
If parents are divorced, who has custody?
If yes, please let us know who is the responsible party for TRAK invoices?
Anything else regarding child guardianship?
Whom may we thank for your referral?
Where did you hear about TRAK?*

For Riding Families: