Stable Moments Participant Application Program Manual Participant Name * First Name Last Name Date of Birth * MM DD YYYY Age * Gender * Height * Weight Participant's Email Participant's Current School * If currently in foster care, what DCBS office is the case in? Primary Phone Number * (###) ### #### Secondary Phone Number (###) ### #### Mailing Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Parent/Guardian Name * First Name Last Name Relationship of Parent/Guardian * Select all that apply. Biological Parent Adoptive Parent Foster Parent Kinship Guardian Other Guardian's Email * Other Guardian Information Please add any other guardians or family/friends who you'd like to receive program notifications via text and email. Include phone and email. How did you hear about the program? * Health History * Please include any medical information you have on your child including past and current medical diagnosis, surgeries, allergies, and precautions. Medications (Include any current prescription and over-the-counter regular medications including name, dose, & frequency) * If none, type none Food/Medication Allergies * If none, type none Date of last tetanus shot * If unknown, type N/A Physical Function (Include information regarding needs when transferring, walking, equipment use, special transportation, and sensory processing) * Psychosocial Function (Include current grade, functioning at school, leisure interest, relationships, family structure, support systems, pets, fears/concerns) * Please list any medical, psychiatric, social or cognitive diagnosis of the participant: * Tell us about your child's foster/adoption story. * What do you hope to gain from this mentorship/ equine assisted program? * What do you see as the participant's greatest strengths? * What do you see as the participant's greatest challenges? * Child's T Shirt Size * 3T 4T Child Small Child Medium Child Large Adult Small Adult Medium Adult Large Adult X Large Adult XX Large Person to be contacted in case of emergency * First Name Last Name Emergency Contact Phone Number * (###) ### #### Second Emergency Contact * First Name Last Name Emergency Contact Phone Number * (###) ### #### Will anyone else be picking up your child or designated to care for your child that we need to know? * Please list anyone that can pick up your child. By typing my name below I am verifying the listed information is true and accurate to the best of my abilities. * First Name Last Name Photo Release * I consent to and authorize the use or reproduction byJustin’s Place of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program. I consent I do not consent By signing below I indicate that I consent or do not consent to the above stated photo release. * First Name Last Name I have been provided a copy of Justin’s Place programming manual and have access to their policies and procedures. I agree to abide by their recommendations and maintain safety while on the property. Thank you for applying to our Stable Moments program! We will be in touch soon regarding your child’s application for services.
