RIDER PROFILE FORM
Today's Date:

Rider Name:

Date of Birth: Age: Gender: Female Male

Care Card Number: Name on Card:

Parent or Legal Guardian Name:

Address: Apartment/Suite:

City: Province: Postal Code:

Phone: (Home) (Cell) (Work)

Email:

Doctor's Name: Phone:

Person filling out this questionnaire:

PREFERED LEARNING STYLE
Auditory (Hearing the information) Visual (Seeing the information) Tactile (Touching, participating)
Likes:
 Dislikes:
Needs:
 Strengths:

Please rate the person(s) ability in the following areas.

Gross Motor Skills
  MAJOR CONCERN MINOR CONCERN NO CONCERN  
Posture Comments:
Easily fatigued Comments:
Coordination Comments:
Awkward gait Comments:
Frequently falls Comments:

Receptive Skills
  MAJOR CONCERN MINOR CONCERN NO CONCERN  
Follows one step direction Comments:
Follows two step directions Comments:
Listens in a group Comments:
Understands basic concepts
(in/out, beside/between, around/over)		 Comments:

Behaviour & Social Skills
  MAJOR CONCERN MINOR CONCERN NO CONCERN  
Ability to share Comments:
Ability to transition Comments:
Abiding by rules and limits Comments:
Attention span Comments:
Temper tantrums Comments:
Unusual fear Comments:
Obsessive by certain topics Comments:

Other Skills
  MAJOR CONCERN MINOR CONCERN NO CONCERN  
Fine motor skills Comments:
Self help skills Comments:
Expressive skills Comments:

Thank you for completing this questionnaire: this will be used to better meet the persons needs and will be confidential to be used within the persons rider profile.