Horse Power
WellPower Student Registration (completed by WellPower staff)

To prepare for this summer’s Horse Power program, we’re asking WellPower staff to complete the following registration, background, and screening form for each student. After completing the form for one student at a time, you’ll be prompted to download a PDF that contains information for the student about what to expect at the ranch as well as two additional documents the student’s legal guardian must complete and sign. We recommend you print the documents for each student and collect the completed and signed documents at least a few days before the first meeting of the program. Both documents 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

Summer

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

WellPower therapist

(If not applicable, please enter "NA.")

Student's mental health diagnosis

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

Yes

If yes, please describe how WellPower 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.

Horse PowerWellPower Student Registration (completed by WellPower staff)

Horse Power
WellPower Student Registration (completed by WellPower staff)