Equine Assisted Learning and Animal Assisted Life skills Scholarship
Participant 1
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First Name
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant 2
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Participant 3
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Guardian Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email (@arizona emails are not accepted)
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Please list some of your strengths! (If multiple participants, please identify each child)
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Please tell us the challenge(s) you are seeking help through our AALS / EAL Program (If multiple participants, please identify each child)
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When did these challenges start?(If multiple participants, please identify each child)
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Has something Happened or changed recently that led you to seek professional Assistance at this time?
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Current Symptom Checklist (check one for any symptom(s) present within the last month, click N/A if not relevant)
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Impulsivity
Difficulty Focusing
Challenges with social situations
Aggression (verbal or physical)
Irritability
N/A
Symptoms for Second Participant
Impulsivity
Difficulty Focusing
Challenges with social situations
Aggression (verbal or physical)
Irritability
N/A
Is there anything else you'd like for us to know?
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Do you have any allergies? If yes, please explain
Do you take any medications that could impair your decision making or movement?
Anything else that we should know about you?
Photo Release
Yes, I allow you to take and use photos and vidoes of particiant
No, I do not allow you to take and use photos and vidoes of particiant
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Ethnicity
Prefer not to answer
White
Black or African-American
Asian
Native American
American Indian or Alaskan Native
From multiple races
Other
Household income
Less than $10,000
$10,000-$24,999
$25,000-$49,999
$50,000-$74,999
$75,000-$99,999
$100,000-$149,999
$150,000 or greater
How did you hear about TRAK?
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Please tell us why you are applying for this Scholarship.
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