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Sign-Up Form for Great Strides (Equine Therapy Program)
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.
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* Indicates required question
Caregiver Name
*
Your answer
Caregiver Email
*
Your answer
Caregiver Phone Number
*
Your answer
Child's Full Name
*
Your answer
Child's Preferred Name (If different from full name)
Your answer
Child's Gender
*
Your answer
Child's Date of Birth
*
MM
/
DD
/
YYYY
Are you currently in, or have you received in the past, services from Spirit Reins?
*
Yes
No
Reason for seeking services
*
Your answer
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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