Cowgirl Club Registration Form
Please allow 5-7 business days for approval or disapproval into our program via Email.
Students’ Information
Student Name
*
First Name
Middle Name
Last Name
Birth Date
Please select a month
January
February
March
April
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June
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December
Month
Please select a day
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Day
Please select a year
2026
2025
2024
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2022
2021
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2019
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1923
1922
1921
1920
Year
Gender
Please Select
Female
Height
*
Weight
*
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guarduan Name
*
First Name
Middle Name
Last Name
Parent/Guarduan Name (Optional)
First Name
Middle Name
Last Name
Person(s) Authorized for Drop Off & Pick Up
*
First Name
Last Name
Guardian Mobile Number
*
Format: (000) 000-0000.
Guardian Mobile Number
Optional
Format: (000) 000-0000.
Emergency Phone Number
*
Format: (000) 000-0000.
Work Number
Optional
Format: (000) 000-0000.
Guardian Email
*
example@example.com
Who is the Student Currently Residing With:
*
Number of Siblings
Please Select
None
1
2
3
4
5+
School Name:
*
Grade:
*
School Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Reason for enrollment into Program:
*
Has student been in trouble with law enforcement?
*
Yes
No
If yes, please explain:
Student have or require an Individualized Education Program (IEP) in school?
*
Yes
No
If yes, please describe:
Student have any Physical/Emotional/Learning Impairment?
*
Yes
No
If yes, please list Diagnosed Impairment
Student currently involved with the Department of Human Resources?
*
Yes
No
Social Worker’s Name:
DHR Case #:
County:
State:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
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Medical Information
Primary Care-Provider
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
City
*
State
*
Zip Code
*
Counselor/Therapist
Optional
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
City
State
Zip Code
List ALL Prescribed Medication & Reason for Medication
*
N/A if needed
Please list ALL known Allergies
*
N/A if needed
Insurance Company
*
List Policy number
Mental Health History
Select Any Applicable Conditions
*
ADD/ADHD
Eating Disorder
Anxiety
PTSD
Bi-Polar
Neurodevelopment Disorder
Borderline Personality Disorder
Shizophrenia
Sexual Trauma
Depression
Suicidal
Disrupted Behaviors
Dissociate Disorder
None
Other
If other, please list:
Medical Emergency Information
Emergency Contact
*
First Name
Last Name
Emergency Contact Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to student
*
Medical Consent Plan
*
Consent Plan - In the event of an emergency, medical aid/treatment is required due to illness or injury during Ranch activities, or while on the property of the agency, I authorize Magnolia Equine LLC/Shorty’s Safe Haven to: Secure and maintain medical treatment and transportation if needed. Release participant records upon request to the authorized individual or agency involved in medical emergency treatment. This authorization includes x-ray, surgery, hospitalization, medication and any treatment procedure deemed “lifesaving” by the physician. This provision will only be invoked if the person(s) are unable to be reached.
Non-Consent Plan - I do not give my consent for emergency medical treatment/aid in the case of illness or injury during Ranch activities or while on the property of the agency. In the event emergency treatment/aid is required, I wish the following procedures to take place.
If you chose Non-Consent Plan - List the following procedures you wish to take place:
Parent/Guardian Signature
*
Parent/Guardian Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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Cowgirl Club Information
Cowgirl Club is our Cowgirl program for girls ages 4-18 in our community. We offer weekly group sessions for girls to meet new friends, learn about animals on the ranch, and participate in interactive activities. Our impact is multi-faced helping Cowgirls of all ages and backgrounds learn, grow, and be themselves. Cowgirl Club does is not primarily a riding program, many activities are led on the ground with horses, or without the horses in a classroom/group setting. Sessions are led by Ranch Moms & Cowgirl Club Alumni, making our program even more special. Our program is open to EVERY COWGIRL.
Horse Riding Experience
*
Pre-Riding (never been on a horse)
Beginner (ridden less than 10 times)
Advance Beginner (taken horseback riding lessons and can perform basic riding skills)
Intermediate (takes/has taken horseback riding lessons consistently, can walk/trot/canter and perform maneuvers, confident and comfortable working with horses.
Do you receive the following:
*
SNAP Benefits
Medicaid
None
Important
If you receive SNAP Benefits or Medicaid for your student our Cowgirl Club Program is no monthly cost. If you do not receive government benefits, program cost is $100 per month. Payment is due on the first of every month (Covering one weekly session each week). No call no show will result in immediate un-enrollment from Cowgirl Club.
Additional Questions or Concerns:
Parent/Guardian Signature
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