Sign-Up Form for Great Strides (Equine Therapy Program)

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Please complete this form if you are interested in enrolling in Great Strides. Our office will contact you about next steps in the registration process.

Caregiver Name *

Caregiver Email *

Caregiver Phone Number *

Child's Full Name *

Child's Preferred Name (If different from full name)

Child's Gender *

Child's Date of Birth *

YYYY

Are you currently in, or have you received in the past, services from Spirit Reins? *

Yes

Reason for seeking services *

What is your availability for group therapy? Please select all that apply. *

Mondays 4:30PM - 6PM

Wednesdays 4:30PM - 6PM

Required

My child is... *

is currently in foster care.

is adopted.

is my biological child.

My child is... *

covered by Medicaid.

not covered by Medicaid.

Would you like to be added to the Spirit Reins newsletter to stay up to date on programming?

Yes, please.

No, thank you.

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