PATH Intl. Profile Form NameEmail Mailing AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipDay PhoneEvening PhoneAre you PATH Intl. Certified Therapeutic Riding Instructor? Yes No If Yes, what level of specialty?RegisteredAdvancedMasterDrivingPlease tell us about any Certifications you have with any Equine Organization: Are you currently or have you ever been affiliated with an Enquine Facilitated Mental Hea;th or Educational Program? Please give us the name and describe you work there.Do you have experience working with Mental Health or Special Educational Clients in any setting? Please tell us where and what kind.Describe other Equine experience you have: PATH Intl. Application Form NameEmail Mailing AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipDay PhoneCheck all that apply: I am at least 21 years old (This is required to attend the workshop/testing) I am PATH Intl Member (please provide number in next fieald) I have called the PATH Intl. office to pay membership needed (if applicable) I plan to participate in the workshop only I plan to participate in the workshop and practical testing I do need an accommodation to complete the practical testing and have contact the PATH Intl. office to request it NOTE: You must be a PATH Intl. member to attend.PATH Intl Member NumberIf you are PATH Intl Member please provide your number.I have enclosed with my application Emergency Medical Forms Profile Form Payment and/or payment information
