Ready, Set, RIDE! Bike Riding Registration

Privacy is very important to us. No information sent to Intensive Therapeutics will in any way be distributed or shared without your acknowledgement and consent.

Instructions to complete registration forms:

Complete the Contact/Medical information below and submit.
Complete and sign the following two (2) forms:
Informed Consent Form
Video/Photo Permission Form
Forms can either be uploaded at the end of this form, mailed to:
Intensive Therapeutics, Inc.
31 Fairfield Avenue
West Caldwell, NJ 07006
OR emailed to: info@intensivetherapeutics.org
*Forms must be completed, signed, and received at least one month prior to program start.

If you are human, leave this field blank.

Desired Starting Date

Registration Information

Child’s Name *

First

Last *

Last

Date of Birth *

Age *

Gender

Parent’s Name *

First

Last *

Last

Home Phone

Cell Phone *

Phone Back Up

Email *

Address *

Address Line 2

City *

State *

Postal Code *

Country

Medical Information

Is your child on medications? *

Yes

Types of medications

Does your child have allergies? *

Yes

Please list allergies

Any other pertinent information?

Family Goals

What are one or two realistic / functional goals you would like to see your son / daughter achieve during this program?

History

Please describe briefly past attempts of participation in sports and current status

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