Hold Your Horses
CRC Student Registration (completed by CRC staff)

To prepare for this semester’s Hold Your Horses program, we’re asking CRC staff to complete the following registration and background information for each student. In addition to this online registration process, please provide each student a printed release and indemnification document that we have already provided to CRC. Each student’s legal guardian must complete and sign this form. We recommend you collect the completed and signed documents at least a few days before the first meeting of the program. The release and indemnification MUST be completed and signed for each student before we can begin the program.

Information shared on registration documents is legally confidential and is considered privileged communication. It will not be shared without written permission of the client, except where disclosure is required by law. More information regarding legal confidentiality can be found in Colorado Revised Statutes 12-43-218 and 13-90-107.

Please remember, this program takes place outdoors in direct contact with horses, on ground that may be lumpy, uneven or muddy. Adequate mobility and limb control are necessary to safely participate in our programs. If you or the student’s legal guardian have concerns about the student’s ability to safely participant in the program, please contact us directly to discuss available accommodations.

REGISTRATION FOR

Semester

Spring

Fall

Year

STUDENT INFORMATION

Name

First Name

Last Name

Prefers to be called

Date of birth

YYYY

Age

Grade

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

County of residence

Guardian's name

First Name

Last Name

Guardian's phone

(###)

###

####

Guardian's email

Has this student participated in the Horse Power program before?

Yes

If yes, how many times?

CRC therapist

Phone

(###)

###

####

Student's mental health diagnosis

Brief description and history of this student's symptoms

If this student has been diagnosed with PTSD or has a significant history of trauma, please provide as much detail as possible related to specific triggers you are aware of and any PTSD management skills we can refer to if the student is triggered during a session:

Specific concerns that contributed to this student's enrollment at CRC

How does this student present at CRC?

Relevant family information affecting this student

Does this student have any learning disabilities, developmental delays, or language barriers that may require accommodations?

Yes

If yes, please describe how CRC plans to make those accommodations and/or what Groundwork Ranch may need to do

Is there anything else we should know before we begin working with this student?

Registration completed by

First Name

Last Name

Relationship to student

FINISH AND SUBMIT

By checking this box, you affirm that the information you've provided in this form is true and accurate to the best of your knowledge.

Hold Your HorsesCRC Student Registration (completed by CRC staff)

Hold Your Horses
CRC Student Registration (completed by CRC staff)