Fall Individual Program Application 2021
Fall Individual Program Application 2021
Thank you for your interest in our Individual Programs! 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 special needs ages 2-12.

For Fall 2021, we will run two 6- week sessions! Either in person or via Zoom!

Session 1 : September 7th – October 18th

Session 2: October 19th – November 29th


Sign ups are on a first come, first serve basis!


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 6 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).

 *In order to maintain a safe social distance between your child and The Barn’s volunteers and staff, at least one adult household/family member must be with your child to provide close, hands-on support to him/her as needed for the duration of his/her IP session.

Throughout the 6 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.
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Email *
GENERAL INFORMATION
Child's First Name *
Child Last Name *
Child's Nickname
Date of Birth *
MM
/
DD
/
YYYY
Age *
Address (Street) *
Address (Apt #, floor, etc.)
City *
State *
Zip Code *
Child lives with: *
PARENT/GUARDIAN INFORMATION
Parent/Guardian Name: *
Relation to Child: *
Address (if different from child):
Home Phone (xxx-xxx-xxxx) *
Work Phone (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx) *
Preferred Method of Contact: *
Parent/Guardian Name: *
Relation to Child: *
Address (if different from child):
Home Phone (xxx-xxx-xxxx) *
Work Phone (xxx-xxx-xxxx)
Cell Phone (xxx-xxx-xxxx) *
Preferred Method of Contact: *
Emergency Contact Name *
Phone Number: *
What school does your child attend? *
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? *
Which Individual Program Session are you Interested In? *
HELP US TO GET TO KNOW YOUR CHILD BETTER
Please identify your child’s disability category: *
Are you willing to share your child’s IEP with the Barn?
Clear selection
PLEASE DESCRIBE THE FOLLOWING ABOUT YOUR CHILD
Ability to communicate wants and needs: *
Ability to follow directions: *
How does your child interact with pets or animals? *
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? *
Please share any other information that you believe would assist us in better knowing your child (special interests or likes/dislikes): *
DE-ESCALATION INFORMATION
Triggers: What makes your child upset, angry, anxious, and/or overwhelmed? Check all that apply: *
Required
Warning Signs: What warning signs does your child exhibit when overwhelmed or in distress? Check all that apply: *
Required
Coping Strategies: What helps your child calm down? Check all that apply: *
Required
Please provide any additional suggestions or effective coping strategies to better serve your child when they are stressed? *
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: *
Does your child require assistance in the bathroom? (children who require assistance in the bathroom will need to be assisted by their parent/guardian) *
Is your child able to wear a mask? *
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: *
If your child has previously attended The Barn's Individual Program, who was their volunteer and would you like them paired with that volunteer again?
INDIVIDUAL PROGRAM AGREEMENT
Please read through this agreement carefully. It has been amended to avoid health risks associated with the COVID-19 virus.

At The Barn at Spring Brook Farm, we strive to create a warm and nurturing environment for your child to grow his/her skills, gain independence, and have fun! Our focus is on the unique connection between animals and children and their special love for one another. Whether it’s feeding a goat, petting a sheep, or grooming one of our miniature horses, we guarantee distinctive and memorable experiences will be had.  With a one-on- one trained volunteer, we consistently work to engage and inspire your child while making sure to complement existing therapies and targeted focus areas.

Our Goal is to:
 - Provide positive and safe animal-assisted activities during your child’s visit to The Barn.
 -  Maintain the lower barn area as a sanctuary for our animals and children – a quiet, tranquil space with low sensory input.
 - Consider your goals for your child when creating a personalized activity plan.
 - Thoroughly train and carefully assign a volunteer matched to your child.  
 - Provide feedback to you following the completion of your child’s individual program.
 - Maintain an “open door” policy should you wish to speak with a Barn staff member for any reason.
 - Take all precautions possible to maintain a safe and healthy environment for your child, supporting family members, our
    volunteers and staff.

In order for us to fulfill our goals and for your child to have the best possible experience, you agree to:
 - Arrive to your child’s IP on time. Out of respect to our volunteers, sessions will not be extended for late arrivals.
 - Park your car in the upper parking lot and a volunteer will meet you at your car to check temperatures prior to the session.
 - Monitor any siblings in attendance at all times to prevent them from venturing into areas intended for our participants and volunteers.**

Cancellation Policy:
If the Barn cancels a session, a make-up session will be rescheduled. IP sessions are held rain or shine.

We understand that occasionally emergencies arise.  Please provide us with at least 24-hour notice if you need to cancel or reschedule your child’s IP session so we can alert your child’s volunteer of the schedule change.

With 24- hour notice, attempts will be made for a make-up session depending upon the availability of a  volunteer to work with your child.

Sessions will not be rescheduled nor any refunds given when a child misses a session without notification (no-shows).

The Barn reserves the right to reassign your child’s spot to another client in the case of repeat cancellations by you.

Thank you for your willingness to provide your child with an exemplary experience here at The Barn.


Your signature below indicates your understanding of, and agreement to comply with the terms outlined above.


Agreement Acknowledgement
Parent/ Guardian Name (This will act as confirmation for the above agreement and application). *
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