Parent / Guardian Name:
Address:
City:
County:
State:
Zip Code:
Home Phone Number:
Cell Phone Number:
Agency:
Case Worker's Name:
Which session would you like to attend?
Saturdays from 10 AM - 12 PM (Fall semester runs from September 10th - December 10th):
Saturdays from 2 PM - 4 PM (Fall semester runs from September 10th - December 10th):
How did you hear about us? (ex. case worker, friend, etc.):
Client 1 Name:
Client 1 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?:
Client 2 Name:
Client 2 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 3 Name:
Client Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 4 Name:
Client 4 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 5 Name:
Client 5 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 6 Name:
Client 6 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 7 Name:
Client 7 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Client 8 Name:
Client 8 Age:
Status: (foster, foster-to-adopt, adopted, sibiling):
What are some goals that you would like your client to accomplish through their participation in the "Horses As Healers" program?::
Comments:
