Reading with Rocky Intake Form
For schools participating in the Healing Reins "Reading with Rocky" Program
School Name
*
School address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Contact Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Contact Email
*
example@example.com
Participating Grades
*
Grade 1
Grade 2
Other
Number of classrooms
*
Total number of children
*
Location provided for the horses visit to school
*
Classroom
Gym
Outdoors
Other
School visit
Date
Time
AM
PM
Blue Moon Stables Field Trip
Date
Time
AM
PM
Submit
Should be Empty: