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Alkira Adina Equestrian

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NDIS Participant Intake Form

Please fill out this form at your own pace. If you have any questions along the way, don’t hesitate to reach out. We look forward to meeting you and learning more about you.

Participant's First name*

Last name*

Parent/ Caregiver name

Email*

Phone*

Birthday*

Day

Month

Year

Address*

NDIS number*

E-mail to send invoice to*

Please choose the code you would like to use*

Capacity building: Innovative Community Participation

Capacity building: Skills development and training

Capacity building: Individual social skills development

Core: Assistance to access community, social and recreational activities

Core: Community, social and recreational activities

Capacity building: Community participation activities

Single choice*

Self managed

Plan managed

NDIA managed (Innovative Community Participation only)

Participant's horse experience*

Participant's weight and height (max 85kg). Please note, Equine Assisted Learning Programs begin on the ground and may include riding in future lessons. *

Upload NDIS plan or a copy of participant's goals (Review INCLUDED in your session cost)

Where any document is uploaded for review, this will be treated as non-face-to-face support time, charged in a minimum 15-minute increment.

Optional file upload

Optional file upload

I understand that if this is a peak-time booking, the time will continue to be reserved for me subject to ongoing payment. I accept that it is my responsibility to cancel any lessons I no longer wish to attend in order to release this time slot.*

I understand

Not applicable to my session

This only applies to peak-time lesson bookings (weekdays 3-6pm and weekends). Regular or non-peak lessons do not automatically reserve this time slot.

I acknowledge that while Alkira Adina Equestrian offers a range of services, including allied health services, it is not a Riding for the Disabled program. Participants must be able to physically engage in activities independently, without the need for hands-on physical support from staff.

I have read, understood and acknowledge the Terms and Conditions (Service Agreement)

I have read, understand and acknowledge Alkira Adina Equestrian's Insurance Waiver provided by their insurance agency. I understand working with horses comes with inherent risk.

Date*

Day

Month

Year

Signature (must be over the age of 18)*

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Name of person signing if under the age of 18.

Maths, Literacy and Communication Education with Horses

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You will find us at

68 Easton Road

Chandlers Hill, South Australia. ABN: 89973109298

©2026 by Alkira Adina Equestrian

Photo credits:

Melissa Claire Photography

Tiffany Smith Photography

Two Tell a Tale

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