Strides Autism Program Application

Strides Autism Program Family Application

Please provide as much information as possible in order to help us fully understand the needs of yourself and your family and accommodate you as best we can. In addition, please provide two written or verbal references from non-family members who have known you and your family for at least two years. Suitable references include teachers, therapists, or other professionals who have worked with you or your child. Include these references in your application and include a phone number and/or email address so we can follow up if necessary.

* Indicates required field

Parent Name (please provide the name of the parent/guardian who will be attending the playdate with your child) *

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Last

Phone Number *

Email *

Parent Name *

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Last

Phone Number *

Email *

Address *

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City

State

Zip Code

Country

Child's Name and Age *

Sibling Name(s) and Age(s) *

Do any of the members of your family who will be attending playdates have any medical conditions/allergies that we need to be aware of? Please be detailed and specific. We need to know this information in case of an emergency. *

Answer the following questions about your child on the autism spectrum. Please be as detailed as possible. This information is used to help us tailor and customize the playdate for your child and your family.

What kind of school is your child currently enrolled in? (mainstream, homeschool, special needs, etc...) *

What grade level is your child in? *

Are you happy with your child's education? If not, why not? *

What are your child's passions? What does he/she like? (For example, Pokeman, Star Wars, dinosaurs, art, etc..) *

What is your child afraid of? What are some negative triggers for your child? *

How does your child communicate? (verbal, non-verbal, augmentative communication device, etc...) *

Does your child have any violent behaviors we should be aware of? Please be honest. If your child does have violent behaviors, this will NOT necessarily prevent him/her from being able to attend a playdate. We need to know in advance so that we can plan accordingly. *

Has your child ridden a horse before? What was his/her reaction? *

What other therapies is your child currently enrolled in? *

Information about your expectations

How did you hear about One Acre Farm and/or Strides Autism Programs? *

Why do you think a One Acre Farm/Strides Playdate is right for you and your child? *

What are your expectations about attending a One Acre Farm/Strides Playdate? *

References and contact information *

Before submitting this form, read the following information and check each box once you have done so. This is important information and we want to ensure that you have read and understood it fully before attending a Strides playdate.

Please check to indicate you have read and accept the rules below. *

Under Texas Law (Ch 75), an equine or farm professional is not liable for an injury to or death of a participant in equine or farm activities resulting from the inherent risk of such activities. Parents or guardians are at all times responsible for all their children. If you do not watch your children at all times we will have to ask you to leave. You, your child and any other person you bring are required to wear proper footwear around the horses/animals at all times. Closed toed shoes are mandatory. Exceptions can be made if your child has sensory issues and with the completion of an additional liability form. Helmets will be provided but it is your responsibility to ensure that they are worn at all times on the horse. Exceptions can be made if your child has sensory issues and with the completion of an additional waiver. Playdates are by confirmed appointment only. Please do not show up without an appointment. If you do arrive and there is no one there, please leave immediately. This is a working farm and we may have dangerous tools, equipment, horses, dogs or other items that are not safe when we are not expecting children or visitors. Please give 48 hours notice of cancellation. If you cancel more than two times, we reserve the right to offer your scholarship to another family. If you do not cancel and you do not show up for a scheduled playdate, we reserve the right to cancel your scholarship and offer it to another family. We reserve the right to cancel a playdate. To the best of our ability, we will give at least 24 hours notice. No pets allowed. Exceptions can be made for service animals after undergoing an evaluation before being brought to a playdate.

If your application is approved, it will entitle you to 8 weekly sessions at which point you will need to submit a renewal form.

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