This is a non-profit corporation dedicated to assisting injured riders. Funds and resources are limited and a committee will select participants in the program. The information on this form is to help us determine if we can be of assistance to you.
Name:______________________________________ E-Mail:____________________
Address________________________________________________________________
Telephone: Home:_______________________Work:__________________________
Contact Person (self or others) _____________________________________________
Address: _______________________________________________________________
Telephone: __________________ E-Mail: ___________________________________
(Please use extra sheets of paper if you need more space for your answers.)
Riding Experience (briefly describe your involvement with horses): ______________
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Describe Injury (as briefly as possible, while still giving specific details): __________
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Describe the type of assistance you are seeking. (Please give a clear detailed description of the assistance you are seeking.)
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Describe the circumstances that require you to seek assistance. This should include an overview of your current financial situation, insurance issues, physical limitations on your ability to perform your job; any area that you might be seeking our help to resolve.
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When you have completed this form please mail it the above address. Should you have any questions filling out or completing this form, visit our web site, www.ameaonline.org; emsaonline.org ; email ameasrf@equestriansafety.org , emsa@equestriansafety.org , or contact us toll free at 866-441-AMEA(2632).
Add any further information you deem important to this initial contact
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