Sign Up Form Student’s Name * First Name Last Name Email * Date of Birth * Mother’s Name & Cell Phone Number * Father’s Name & Cell Phone Number * Other Legal Guardian, Relationship Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Emergency Contact * Emergency Contact Phone * (###) ### #### Does the student currently have any conditions or limitations that might impair his/her physical ability or compromise his/her ability to remain alert and thinking while engaged in equine facilitated activities? If Yes, please explain in message box below. Yes No Does the student have any food or insect bite allergies? If yes, please explain in message box below. Yes No Does the student have any medical conditions that need the attention of program staff? (i.e. inhalers, medication, et cetera) * If yes, please explain in message box below Yes No School Name & Address Grade in Fall 2023 Approximate reading level Above Grade Level At Grade Level Below grade Level Unsure Favorite & Least Favorite Subjects Subject student excels or struggles in? Has the student been receiving tutoring or extra help? If so, what subject(s)? From whom? Does the student have either of the following? * an IEP a 504 Plan Neither Which activity are you registering for? Summer Fun Camp ($300 / Session, $50 Deposit) Session 1 : June 6 - 9 Session 2 : June 13-16 Session 3 : June 20 - 23 Session 4 : June 27 - 30 Session 5 : July 4 - 7 Session 6 : July 11 - 14 Session 7 : July 18 - 21 Session 8 : July 25 - 28 May Book Club ($100 / Session, $25 Deposit) 4th — 8th Grade, Tuesday 4:30pm to 6pm K - 3rd Grade, Thursdays 4:30 to 6pm Saturday Afternoon Read Aloud ($25 / child, pay at the door) April 22, 2023 at 2:30pm May 13, 2023 at 2:30pm June 17, 2023 at 2:30pm July 15, 2023 at 2:30pm Individual Session ( $65 / Session, Packages available) Reading Writing Math How would you like to make your deposit? Registration is not complete until deposit is received. Venmo Paypal Cash Thank you for your submission!
