CONCHO Participant Referral Form
Concho is a free adaptive horsemanship program designed for adolescents and young adults (ages 12-23) who are navigating stress, anxiety, and depression. Through hands-on interaction with horses, participants will build confidence, develop emotional awareness, and gain valuable coping skills in a supportive environment. Horse experience is not required to be a participant in this program. Please note space is limited to ten participants for each session. If you are not selected for participation this time around,  we will keep your contact information for future sessions! 

Program Details:
Dates: Saturdays, Dates Determined by Semester (more info will be sent via email)
Duration: Approximately 2 hours per session
Location: Temple Grandin Equine Center, 725 S Overland Trail, Fort Collins, CO 80521
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Who is filling out this form? *
Full Name of Participant *
Participant Date of Birth (MM/DD/YYYY) *
Parent/Guardian Name *
Parent/Guardian Email *
Parent/Guardian Phone Number *
Home Address *
School District *
Gender *
Weight *
Height *
Please list any relevant diagnoses or conditions of participant pertaining to receiving services. *
Medical History (please provide all relevant information) *
Has participant had (or is currently having) seizures? If so, please describe type and date of last incident.  *
Does the participant use any assistance devices? *
How did you find our services? *
Describe why the participant is seeking services through Concho. *
Presenting problems, concerns, or challenges? *
What is the participant's previous horse experience? (No experience required!) *
Would the participant be comfortable in a group setting? *
I certify the above information to be up to date and accurate to the best of my knowledge. *
Required
Signature (if filled by a minor, please have parent or guardian sign) *
Signature Date *
MM
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DD
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YYYY
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