Individual Programs Application 2019
Thank you for your interest in our Individual Program! This application is required for all children who wish to participate. The Individual Program utilizes one-on-one volunteers to facilitate animal-assisted activities for children with disabilities and special needs ages 2-12. The program runs for 12 weeks in the spring (March 1 - May 31), summer (June - August) and fall (September 1st – November 30th). Sessions occur for one hour per week 2:00pm-6:00pm Monday through Friday.

Your acceptance into the program is based on review of this application and an on-site visit
at The Barn at Spring Brook Farm with our Program Manager.

After initial contact with the Program Manager, the standard process for participation is as follows:

Step 1: Schedule an on-site visit
- Parent(s) and child tour the facility with Program Manager
- Parent(s) completes application
- Program Manger conducts initial assessment

Step 2: If the Program Manager believes that the child will benefit from the program, parent(s) schedule a meeting to
- Identify goals face-to-face or by phone, without child
- Identify specific goals for the child’s Barn Activity Plan
- Discuss strategies for integrating animals into the goals

Step 3: Program Manager will identify an appropriate volunteer to work with the child
- Confirm schedule
- Review relevant information related to the child and Barn Activity Plan with the volunteer

Step 4: Begin 12 weeks of visits to The Barn
- Volunteer and child work together towards goals identified in the Barn Activity Plan with support and observations from the Program Manager and mid-term input from parent(s)

Throughout the 12 weeks of visitation, the Program Manager will meet with the volunteer after each visit to debrief, discuss progress during the visit, and make adjustments to strategies as necessary.

After the final visit, the Program Manager will provide a final report to the parents and discuss strategies and goals for future sessions.

Email address *
GENERAL INFORMATION
Child's Name *
Your answer
Child's Nickname
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Address (Street, City, State, Zip) *
Your answer
Child lives with: *
Your answer
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name: *
Your answer
Relation to Child: *
Your answer
Address (if different from child):
Your answer
Home Phone (xxx-xxx-xxxx) *
Your answer
Work Phone (xxx-xxx-xxxx)
Your answer
Cell Phone (xxx-xxx-xxxx) *
Your answer
Preferred Method of Contact: *
Parent/Guardian Name: *
Your answer
Relation to Child: *
Your answer
Address (if different from child):
Your answer
Home Phone (xxx-xxx-xxxx) *
Your answer
Work Phone (xxx-xxx-xxxx)
Your answer
Cell Phone (xxx-xxx-xxxx) *
Your answer
Preferred Method of Contact: *
Emergency Contact Name *
Your answer
Phone Number: *
Your answer
Has your child ever participated in programs at The Barn? *
If yes, which program(s)? *
Required
How did you find out about our Individual Program?
Your answer
Help us get to know your child better
Please identify your child’s disability category: *
Your answer
Are you willing to share your child’s IEP with the Barn?
Please describe the following about your child:
Ability to communicate wants and needs: *
Your answer
Ability to follow directions: *
Your answer
Ability to be redirected: *
Your answer
How does your child handle stress? Please describe his/her coping skills: *
Your answer
How does your child handle stress? Please describe his/her coping skills: *
Your answer
How does your child interact with pets or animals? *
Your answer
Are there any specific strategies you suggest we use to support your child, including specific motivators, and/or ways to help modify your child’s behavior? *
Your answer
Please share any other information that you believe would assist us in better knowing your child (special interests or likes/dislikes): *
Your answer
MEDICAL INFORMATION:
Please indicate if your child uses any of the following assistive devices: *
Required
If your child has any allergies, please describe the allergy and reaction: *
Your answer
Does your child require assistance in the bathroom? (children who require assistance in the bathroom will need to be assisted by their parents)
SCHEDULING
Please indicate which days/times your child would be available to attend programs:
Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
If your child will be accompanied by support staff such as a TSS or PCA, please provide the person’s name, title and agency: *
Your answer
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