Horse Powered Reading® Participant Application

Horse Powered Reading® Participant Application

Memory Lane Farm, Inc. 8640 Heritage Dr., Marshfield WI 54449
The following application is to be completed for all Memory Lane Farm Horse Powered Reading program participants. This form has been designed to provide necessary information to our facilitators before our initial session in order to make the most productive and efficient use of our time together. All information provided is strictly confidential and will not be released without written consent.
GENERAL CONTACT INFORMATION
Today's Date:*

MonthDayYear
Date
Name of Applicant:*
Desired Program*

Horse Powered Reading - All Ages, Individual Sessions(6-8 weeks) $60/SessionHorse Powered Reading - All Ages, Small Group Sessions(6-8 weeks) $60/SessionBooks & Broncos Book Club - 7th-8th Graders(Fall 2023)(6 weeks)
Address:*
City*
State*
Email:*
example@example.com
Phone:*
Emergency Contact Name:*
Emergency Phone:*

Area CodePhone Number
Relationship:*
Referral source name:*
Who suggested this program to you?
MINOR’S INFORMATION
Child's Last Name:*
Child's First Name:*
Nickname:
Parent(s)/Guardian Legal Name:*
Birthday:*
Age of Child:*
Grade of Child:*
Current grade
Child's School:*
Teacher's Contact Information*
Name, Phone Number, Email
Can we contact your child's teacher to best accommodate and support their classroom learning?*

No, not at this time.Yes!
PROGRAM INFORMATION

(completed by parent/guardian)
How can your child benefit from this program (be as specific as possible):*
Are there issues that you feel our leadership team should be made aware of (medical, allergies, emotional, behavioral, physical limitations, etc.)*
Is your child able to identify concerns and ready to work toward making changes in learning?*

No, not at this time.Yes!
REQUIREMENTS FOR PARTICIPATION
We understand that this is a farm-based program whereby participation is necessary.. I attest that my child wants to participate and understands the general goals of the program.
Please Initial:
LIABILITY WAIVER
All guests, participants and volunteers are required to sign a Liability Waiver and photo release waiver in order to participate in our programs, as required by our insurance. Waivers will be provided at the time of applying for our program. Waivers are kept on file for one calendar year.
SCHEDULING
Memory Lane Farm's Horse Powered Reading program is a popular and invested program where staff and volunteers selflessly give their time to serve you/your family. If you are more than 10 minutes late for your scheduled session for any reason, that time may be repurposed. A phone call or text (not email) to 715.897.7187 is required for any cancellation or tardiness.

Missed sessions will not be rescheduled. If you are late or miss two or more sessions in a season, the spot MAY be forfeited for the remainder of the current session season.
COMMUNICATION
All participant application and personal information is considered confidential and only information critical to the success of the participant will be shared with our Horse Powered Reading Certified Facilitators.

The Staff at Memory Lane Farm come with many years of education and life experience. We desire to play an important and impactful role in the development of our participants.

Staff and volunteers of Memory Lane Farm, Inc. are not counselors, therapists or are authorized to offer any professional advice. We, however are happy to offer resources for families and participants.

I have read and understand the Participant and Parent/Guardian Guidelines as stated above:
Participant/ Parent/Guardian Printed Name*
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Horse Powered Reading® Participant Application

GENERAL CONTACT INFORMATION

MINOR’S INFORMATION

PROGRAM INFORMATION

REQUIREMENTS FOR PARTICIPATION

LIABILITY WAIVER

SCHEDULING

COMMUNICATION