Foster care to Success

Foster Care to Success

Fill out the form carefully for registration
Which program are you interested in?

Spring Break CampSummer CampFall Break CampWinter CampEquine Assisted Leaning/ Animal Assisted Life Skills
Participant 1*

First NameLast Name
Birth Date*

MonthDayYear
Age of Participant*
Has Participant 1 been in Foster Care

YesNo
Participant 2

First NameLast Name
Birth Date

MonthDayYear
Date
Age of Participant
Birth Date

MonthDayYear
Date
Has Participant 2 been in Foster Care

YesNo
Guardian Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
Guardian E-mail (@arizona emails are not accepted)*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact #1*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact #2*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Please list some of your strengths! (If multiple participants, please identify each child)*
Please tell us the challenge(s) you are seeking help with through our Program (If multiple participants, please identify each child)*
Please list some of your strengths! (If multiple participants, please identify each child)*
Please list some of your strengths! (If multiple participants, please identify each child)*
Current Symptom Checklist (check one for any symptom(s) present within the last month, click N/A if not relevant)*

ImpulsivityDifficulty FocusingChallenges with Social SituationsAgression (verbal or physical)IrritabilityN/A
Symptoms for Second Participant

ImpulsivityDifficulty FocusingChallenges with Social SituationsAgression (verbal or physical)IrritabilityN/A
Comments below regarding Symptom Checklist(s)*
Do you have pets in the home?*
Have the Child(ren) had previous experiences with horses? Please explain. *
Is there anything else you would like us to know?*

Foster Care to Success

Demographic Information