Blue Sky Moments Application/Guardian Packet

Blue Sky Moments Program

Application for enrollment
Vision: We seek to help all people walk in their God-given destiny and purpose.

Program Overview: The Blue Sky Moments is a Christ-centered equine mentorship program that seeks to improve the life course of individuals that have experienced some form of trauma, including foster care children and kids with disabilities. We utilize community mentors, Christian principles and equine facilitated learning to assist in developing life skills. We provide support for guardians and parents, promote permanency in foster families and cultivate an environment where individuals learn that they not only matter to us, they matter to God.

Program History: Blue Sky Moments began right alongside the birth of Blue Sky Acres in the Spring of 2021. We saw the tremendous need in our community for a program that brings together horses and children of trauma or disabilities in a one-on-one mentorship model. There is nothing else like it being offered in our area.

What we offer:The Blue Sky Moments program typically runs for ten weeks each school semester. The longer participants have access to the same mentor and horse, this can create a foundation for stability that hopefully will overflow into other areas of their lives. Each groundwork only session with the mentor and horse builds on the last one, thus continuing to develop that relationship.

Who we serve: We serve individuals with disabilities as well as those that have been through a crisis or trauma. So many foster children have experienced some form of trauma, affecting their human development and the way they interact at home, in school and the community. Without therapeutic intervention, many children are at a high-risk of repeating the destructive cycle of their parents after they age out of foster care. We minister to individuals ages 10 and up, along with offering support and prayer to their families.

Program Schedule: The Blue Sky Moments program will run on a semester schedule both in the fall and spring concurrent with the local school calendar. It will consist of a one hour a week session with a mentor for ten weeks at the Blue Sky Acres facility.

WHAT CAN BE EXPECTED:
- Intake assessment to get an understanding of the participant's history, strengths, challenges and goals
- Develop an individualized plan of care- life skill goals, short and long term objectives
- Participant is paired with a mentor who meets with him/her once a week
- Participant has access to the same horse each week
- Mentor and participant engage in groundwork only learning activities with the horse; no riding is involved
- Each session begins with reading a page out of a Christian devotional
- Program t-shirt
- Activity logs completed at the end of each session
- Mid-year and final summary detailing the participant's progress in the Blue Sky Moments program

Participant Policies

1. Participants must wear close-toed shoes (boots preferred). Long pants are recommended. Anyone wearing inappropriate clothing with obscene or offensive language or graphics will be asked to cover up. Loose or dangling jewelry such as earrings, necklaces or bracelets are not recommended and can be a safety issue due to the nature of a working farm or ranch. If a participant arrives without proper shoes a non-equine activity will have to be chosen instead.

2. In the case of rain, the Session Leader will monitor the forecast and determine whether or not sessions will be canceled. The parent/guardian will be notified a minimum of 1 hour prior to the scheduled session in the case of cancelation. In the case of severe weather such as extreme heat, thunderstorms, hurricanes or very windy conditions, sessions are to be canceled at the discretion of the Session Leader. Sessions will also be canceled if the temperature high for the day is below 40 degrees.

3. Participants must give a minimum of 4 hours notice if they need to cancel a session. More time is better so we can alert the mentor. After three sessions are missed in a semester without appropriate notice, that participant will be asked to sit out the rest of the semester. * Please notify the Program Director of any conflicts with your participant’s scheduled session time at the beginning of the semester.

4. We encourage all participants to arrive early to their scheduled session. Each private session lasts one hour and will not be extended past the scheduled time slot. Ex. If you arrive 20 minutes late then your participant only has 40 minutes left of that session for any activities.

5. Parents and siblings should remain on property in their vehicles or in designated parent spots for the duration of the session.

6. Mentor and child will participate in groundwork only learning activities with their assigned horse. No riding is involved.

7. I understand that information about the participant (name, goals, progress notes, etc.) will remain confidential. Our Mentors and Volunteers are asked to sign a confidentiality policy regarding participants and what happens in sessions.

Please sign below saying that you have read the above policies and understand them.
Participant Name*
Signature of DFCS Case Manager (if applicable)

Clear
Signature of Foster Parent or legal Guardian if under 18

Clear
Date*

MonthDayYear
Date

Participant Registration

and Guardian Consent form

Please fill out the participant information below if you are over 18 years old.

*DFCS Case Manager or Legal Parent/Guardian:

Your child has been invited to participate in our Blue Sky Moments program. We have trained volunteer mentors that have dedicated their time to serve the children. Your child's mentor will only visit with him/her on-site during Blue Sky Moments scheduled sessions.

Your signature indicates your permission:

1. For your child to participate in the Blue Sky Moments program.

2. For pertinent information regarding your child, including but not limited to: history, challenges, strengths, interests and goals be distributed to the assigned volunteer mentor.

All information listed below is confidential and will only be seen by the Blue Sky Moments Executive Director, Program Director and your child's assigned volunteer mentor.
PARTICIPANT NAME*
DATE OF BIRTH*

MonthDayYear
AGE*
Sex:*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PRIMARY FOSTER PARENT or LEGAL GUARDIAN NAME (IF UNDER 18)
CELL PHONE*
HOME PHONE
FOSTER PARENT or LEGAL GUARDIAN EMAIL
example@example.com
SECONDARY FOSTER PARENT OR LEGAL GUARDIAN NAME (IF APPLICABLE)
PHONE NUMBER OF SECONDARY PARENT/GUARDIAN
Please enter a valid phone number.
AUTHORIZED EMERGENCY CONTACT*
EMERGENCY CONTACT PHONE NUMBER*
SCHOOL ATTENDING (IF APPLICABLE)
GRADE
ETHNICITY (for grant purposes)*
Participant Signature (if over 18)

Clear
Date

MonthDayYear
DFCS Case Manager Signature (if applicable)

Clear
Date

MonthDayYear
Date
Foster Parent or Legal Guardian Signature (if under 18)

Clear
Date

MonthDayYear
Date

GENERAL ACTIVITY RELEASE, ASSUMPTION OF RISK and WAIVER OF LIABILITY AGREEMENT

*This document waives important legal rights. Read it carefully before signing.*

I AGREE that I /my child /my ward choose to participate voluntarily in Blue Sky Acres activities as a rider, handler or spectator. I am fully aware and acknowledge that horse sports and Blue Sky Acres activities involve inherent dangerous risks of accident, loss, and serious bodily injury including, but not limited to, broken bones, head injuries, trauma, pain, suffering or death ("Harm"). I fully understand that this release covers, but is not limited to, inherent risks of an equine activity, which mean a danger, or condition that is an integral part of an equine activity, including but not limited to, any of the following:
- The propensity of an equine to behave in ways that may result in injury, death, or loss to persons on or around the equine;
- The unpredictability of an equine's reaction to sounds, sudden movement, unfamiliar objects, persons, or other animals;
- Hazards, including, but not limited to, surface or subsurface conditions;
- A collision with another equine, another animal, a person, or an object;
- The potential of an equine activity participant to act in a negligent manner that may contribute to injury, death, or loss to the person of the participant or to other persons, including but not limited to, failing to maintain control over an equine or failing to act within the ability of the participant.
I AGREE that I /my child/ my ward would like to participate in the Blue Sky Acres program. I acknowledge the risks and potential risks of horse activities in and around a facility where horses are kept and farm machinery operated. However, I feel that the possible benefits to me/ my child/ my ward are greater than the risk assumed. I hereby, intending to be legally bound for myself, my heirs and assigns, executors or administrators waive and release forever all claims for damages against Blue Sky Acres, its Board of Directors, instructors, therapists, aides, volunteers, employees, and affiliated organizations for any and all injuries and/or losses I may sustain while participating in the Blue Sky Acres programs including activities occurring outside of the scope of the program itself, including, but not limited to transportation, caregiving, horse exercising etc. This release includes without limitation the risk of negligent instruction and supervision.

By signing below, I ACKNOWLEDGE that I enter into this release after having read the same, and place my signature hereto of my own free voluntary act and deed.

By signing below, I represent to Blue Sky Acres that I fully understand the contents of this document, that I do not need any further explanation, and I waive any further explanation.

I AGREE to assume all risks of injury, harm, death and property damage that may result to me and/or my child/my ward. I agree to bear any loss myself. I also specifically agree to the GEORGIA LIABILITY LAW regarding equine/farm animal activity liability: Under Georgia Law, an equine activity sponsor or equine professional is not liable for an injury to or the death of a participant in an equine activity resulting from an inherent risk of equine activity, chapter 12, Title 4 of the official code of Georgia annotated.

ACCEPTED BY: (if under the age of 18 years old, there must be a legal guardian signature below):

Both date and signature MUST be completed.
PARTICIPANT NAME (Printed)*
DATE*

MonthDayYear
Date
PARTICIPANT SIGNATURE (DFCS Case Manager or Legal Guardian Signature if participant is under 18 years old)*

Clear

PHOTO RELEASE
I DO consent to and authorize:I DO NOT consent to nor do I authorize:
1. Blue Sky Acres to use and reproduce any photograph or image in its print, online and video publications of me/my child/my ward for distribution to the public for promotional printed materials, educational activities or for any other use for the benefit of the program;
2. to release Blue Sky Acres, its employees and any outside parties from all liabilities or claims that I might assert in connection with the above-described activities and
3. to waive any right to inspect, approve or receive compensation for any materials or communications, including photographs, videotapes, DVDs, website images or written materials, incorporating photos/images of me/my child/my ward.
Please sign below confirming your choice:
PARTICIPANT SIGNATURE (DFCS Case Manager or Legal Guardian if under 18) *

Clear
DATE*

MonthDayYear
Date

Authorization of Emergency Medical Treatment

In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving services, or while being on the property of the agency, I authorize Blue Sky Acres to secure and retain medical treatment and transportation if needed and release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Physicians Name*
Physician's Phone*
Preferred Medical Facility*
Health Insurance Company*
Insurance Policy #
Consent Plan

Signing this gives consent to an x-ray, surgery, hospitalization, medication and any treatment procedure deemed "life saving" by the physician. This provision will only be invoked if the person below is unable to be reached.
PARTICIPANT CONSENT SIGNATURE (DFCS or Legal Parent or Guardian if under 18)

Clear
Date

MonthDayYear
Non-Consent Plan

I do not give my consent for emergency medical treatment/aid in the case of illness or injury during the process of receiving services, or while being on the property of Blue Sky Acres.
In the event emergency treatment/aid is required, I wish the following procedures to take place:
PARTICIPANT NONCONSENT SIGNATURE (DFCS or Legal Parent or Guardian if under 18)

Clear
Date

MonthDayYear

Staff and Mentor Policies

At BSA we consider it a privilege and a blessing to work with each program participant. We take this opportunity very seriously and require our staff and volunteer mentors to sign and follow the Code of Conduct below.
1. In order to protect BSM program participants, staff and volunteer mentors, at no time may a staff person or mentor be alone with a child where a staff member or mentor cannot be observed by others.

2. Mentors and staff will never leave a child unsupervised.

3. Mentors and staff will never take a child to the restroom alone.

4. Mentors and staff will not abuse children and supervise corporal punishment of any kind. This includes physical abuse, verbal abuse, sexual abuse, mental abuse, or neglect. Any type of abuse will not be tolerated and is cause for dismissal.

5. Mentors and staff will use positive techniques of guidance, including positive reinforcement, redirection, and encouragement rather than anger, condescending words, and harsh criticism.

6. Mentors and staff will respect children's rights to not be touched in ways that make them feel uncomfortable. A child's right to say "NO" is to be encouraged and respected. Children are not to be touched in areas of their bodies that would be covered by a bathing suit.

7. Mentors and staff will not give gifts or special favors to individual children.

8. Mentors and staff will not have any form of private interaction through social media, computer or handheld devices with any children in the program.

9. Pictures will not be taken of any child by mentors. Only BSA staff will take photos if given written permission by the parent/guardian ahead of time.

10. Mentors and staff will respond to children with respect and consideration and treat all children equally regardless of gender, race, religion, sexual identity, or culture.

11. Possessing, using or being under the influence of alcohol or illegal drugs in or on the property is strictly prohibited.

12. Profanity, inappropriate jokes, and any kind of harassment are prohibited.

13. Staff and mentors are not to transport children alone in their own vehicles.

14. Under no circumstances should staff or mentors release children to anyone other than the authorized parent, guardian or other adult authorized by the parent or guardian. Exceptions made will require written parent authorization to be put on file with Blue Sky Acres.

15. Mentors and staff are required to report any suspicion of child abuse to the Blue Sky Acres Executive Director or Program Director as well as the proper authorities.

*Any violation of this Code of Conduct may result in dismissal of staff and/or volunteer mentors.

BARN RULES TO FOLLOW
- Appropriate attire and footwear is needed to work with the horses for the safety of everyone. Closed-toed shoes, preferably boots are required. A participant wearing inadequate footwear can only participate in non-equine activities.
- Participants must shut all doors and gates to the barn, stalls, paddocks and arena. It is not permitted to climb over gates or fences.
- Participants are not to enter a field or stall without the supervision of a mentor. Participants are not to remove a horse from a stall or field without supervision of a mentor.
- No running or sudden movements
- Respect others: clean up after yourself and your horse
- Participants are not allowed to handle horse feed or feed horses treats without supervision
- Make sure the horse is aware of your presence before approaching
- Never walk or stand behind or go under a horse
- Always use a halter and lead line when moving a horse
- Participants are not permitted in the tack room without supervision of a mentor and should only handle items related to their session plan.
- If you are unsure of what you are doing, ask for help!
By signing below, I acknowledge that I have read and understand the barn rules.

*Parent/legal guardian/foster parent please sign below that you have gone over these rules with the participant.
PARTICIPANT SIGNATURE*

Clear
Date*

MonthDayYear
Date
FOSTER PARENT OR LEGAL PARENT OR GUARDIAN SIGNATURE

Clear
DATE

MonthDayYear

GETTING TO KNOW YOU

We would love each participant to fill out this page for the mentor to get to know a little about you prior to the first session.
My full name is:
Please call me:
(The name I go by)
My birthday is
My current grade in school (if applicable):
My favorite food is:
Some of my interests, hobbies and/or things I like to do:
Something I hope to learn about horses:
Please supply any other details about yourself that you think would be helpful for your mentor to know about you before your first session.
Should be Empty:

Blue Sky Moments Program