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Kiddy Up Ranch Participant Intake Forms

The following student intake form is to be completed for all Kiddy Up Ranch program participants. This form has been designed to provide necessary information before our initial session in order to make the most productive and efficient use of our time together. All information provided is strictly confidential and will not be released without written consent.

Name

This field is for validation purposes and should be left unchanged.

Specify the program you are particularly interested in

Name of Parent or Legal Guardian(Required)

First Last

Are you the parent or legal guardian?(Required)

I am the parent

I am the legal guardian

Your complete address(Required)

Street Address Address Line 2 City State ZIP Code

Your email(Required)

Enter your email Confirm your email

Your best contact number(Required)

Is this number suitable for sending text message correspondences?

Yes

Emergency Contact

List the name of your designated emergency contact?(Required)

First Last

What is the primary emergency contact's phone number?(Required)

What is the primary emergency contacts relationship to the minor?(Required)

Would you like to add an additional emergency contact?

Yes

Furnish any additional information about your additional emergency contact(s) in the space below, including their relationship to the minor.

Were you directed to our services by an existing contact or referral?(Required)

Yes

Could you please tell us who referred you to this program? We'd like to thank them.(Required)

PARTICIPANT'S INFORMATION

Student's First & Last Name

First Last

Nickname

What is their birthday(Required)

MM slash DD slash YYYY

Age of child(Required)

Grade of child(Required)

What school do they attend?(Required)

May we have permission to contact your child's teacher to best accommodate and support their classroom learning?(Required)

Yes

Teacher's contact information(Required)

Has your child participated in tutoring or reading activities before?(Required)

Yes

Does your child currently have an IEP (Individualized Education Program) in place at their school?(Required)

Yes

I'm not sure

Could you please specify the areas in which you aim to set goals?(Required)

PROGRAM INFORMATION

How can your child benefit from this program (be as specific as possible)?(Required)

For your child's safety and to help us support them best, please tell us about any important things we should know. This could be about medical issues, allergies, emotional or behavior issues, physical limitations, etc. It's really important that you give us all the information, so we can do our best for your child.(Required)

Kindly indicate any of the following academic or learning areas where you have concerns for your child. Please CHECK ALL THAT APPLY, bearing in mind that some options may not be relevant based on your child's age.(Required)

Rhyming and Word Play

Alphabet/Letter Sound Knowledge

Sounding our CVS (consonant - vowel - consonant) Words (i.e. cat, fig)

Reading Grade Level Sight Words

Forming Letters in Writing

Writing Words

Writing Grade Level Sentences

Mechanics/Conventions of Writing

Asking or Answering WH (Who, What, Where, When, Why) Questions

Comprehending Informational Text

Retelling Stories/Summarizing Text

Vocabulary Knowledge

Understanding Non-Literal Language

Verbal Reasoning/Problem Solving

Listening/Attending/Focusing

Motivation

Lacks Interest

Intense, Special or Spikes of Interest

Reading with Ease and Speed

Reading with Voice ("In Character")

Number Sense and Counting

Math Skills

Other

Since you've selected "Intense, Special or Spikes of Interest" in the previous section, kindly detail those specific interests here. They could be anything from airplanes to a favorite TV show or video game. Take as much room as you need to describe their talents..(Required)

Since you have selected the "OTHER" category in the previous section, we kindly request you to enumerate those specific items or concerns in the space provided below.(Required)

Is your child able to identify concerns and ready to work toward making changes in learning?(Required)

Yes

I'm not sure

REQUIREMENTS FOR PARTICIPATION

Consent(Required)

I hereby agree, and my child is enthusiastic about participating as well..

I acknowledge that this program takes place on a farm and emphasizes a hands-on learning approach that necessitates active participation.

Furthermore, I confirm that my child is enthusiastic about participating and is aware of the fundamental goals of the program.

LIABILITY WAIVER

Consent(Required)

I agree.

As a matter of protocol, all guests, participants, and volunteers engaging with Kiddy Up Ranch are mandated to sign both a Liability Waiver and a Photo Release Waiver prior to participation in any of our programs.

This requirement is in line with our insurance provisions. These waivers will be provided for signing during the final application process for our programs.

Please note, all signed waivers are securely maintained on file for a period of one calendar year.

Thank you, we've received your information.Need to add another child? Use the same form below.

Kiddy Up Ranch Participant Intake Forms

Emergency Contact

PARTICIPANT'S INFORMATION

PROGRAM INFORMATION

REQUIREMENTS FOR PARTICIPATION

LIABILITY WAIVER

Thank you, we've received your information.
Need to add another child? Use the same form below.