Driver Information Form

Name _________________________________________________________________________
Address _______________________________________________________________________
Phone ________________________ Email _______________________________ Age _________
What is your driving experience, if any? ________________________________________________
______________________________________________________________________________
Are you familiar with the harnessing & hitching proper sequence? _____________________________
How many professional care givers do you require? _______________________________________
Do you use a wheelchair? _____ If so, is it manual or electric? _______________________________
Will you require any upper body support for balance on uneven terrain? ________________________
Can you grip with your hands? ____________________ Do you grip with one hand better than the other?
______________________________________________________________________________
Are their any other physical limitations we should be aware of? _______________________________
What are your ambitions as a driver? __________________________________________________
______________________________________________________________________________
Do your own your horse/pony and carriage/cart? Describe __________________________________
______________________________________________________________________________
What do you hope to gain from the mentorship program? ___________________________________
______________________________________________________________________________
Describe the safety precautions and adaptations you use during driving:
Horse Harness or reins _____________________________________________________________
Mounting the carriage ______________________________________________________________
Personal harness/safety belt __________________________________________________________
During driving ____________________________________________________________________
Dismounting from the carriage ________________________________________________________
Holding the whip __________________________________________________________________
Other __________________________________________________________________________

Please return this file to the USDFD Office:
United States Driving for the Disabled
c/o Mentorship Program
3329 Cynthiana Rd
Georgetown, KY 40324

We will be contacting you shortly regarding your possible mentor. Thank you for your interest in mentoring. Through your efforts, more people will be able to have freedom of mobility while experiencing the incredible connection between equine and driver.