Fall 2024

Registration

FALL 2024 REGISTRATION

LESSON DATES & TIMES

Sundays (8:30 am-12:30 pm)

Sept 8, 15, 22, 29, Oct 6, 27, Nov 3, 10, 17, 24, & Dec 8, 15

Mondays (3-6 pm)

Sept 9, 16, 23, 30, Oct 7, 21, 28, Nov 4, 11, 18, & Dec 9, 16

Tuesdays (3-6 pm)

Sept 10, 17, 24, Oct 1, 8, 22, 29, Nov 5, 12, 19, & Dec 10, 17

Wednesdays (3-6 pm)

Sept 11, 18, 25, Oct 9, 23, 30, Nov 6, 13, 20, & Dec 4, 11, 18

Thursdays (3-6 pm)

Sept 12, 19, 26, Oct 10, 24, 31, Nov 7, 14, 21, & Dec 5, 12, 19

Individual lessons are 30 minutes beginning on the hour and half hour.

Program dates are also posted in the calendar on the bottom of our home page: ponypowernj.org

Please note: Submitting a form does not guarantee enrollment. Enrollment is not finalized until you have been contacted by Pony Power staff and we have agreed upon a schedule for the semester.

SELECT YOUR SERVICE(S)

Choose "1" in the quantity field for your desired program(s) from the options below.
To participate in the program more than one time per week, select "2" in the quantity field.
One participant per registration form. Siblings must be registered on separate forms.
When registering for Sibling Riding, you must have at least one child enrolled in Therapeutic Riding.

Therapeutic Riding: $1020 for 12 lessons
Lessons are 30 minutes with 1:1 instruction.

Quantity of TR

Sibling Riding: $780 for 12 lessons
Lessons are 30 minutes with 1:1 instruction. To be eligible for the sibling rate, at least one other child must be enrolled in Therapeutic Riding.

Quantity of SR

Horse-assisted Learning: $780 for 12 lessons
Lessons are 30 minutes in this non-riding program with 1:1 instruction focused on grooming and horsemanship.

Quantity of HL

All Hands In Group Program: $660 for 12 sessions
Tuesdays, 4:30-6 pm. Small group of young adults who connect socially through activities on the farm. An interview is required of new participants prior to registration for this small group program.

Quantity of AH

Forest Babies Group Program: $400 for 8 lessons
Offered 9:30-11:30am for the first 8 Wednesdays, ending November 13, this inclusive group is for children ages 1.5 to 4. Together the group discovers the wonders of farm life and explores touch, taste, smell, sight and sound in nature through this unique series of this small group class. This class is non-riding. A parent or caregiver needs to stay with their child for the duration of the program.

Quantity of FB

Supported Volunteering: $420 for 12 lessons
Individual one-hour lessons for teens and young adults seeking to build vocational habits and skills by volunteering with the help of a Pony Power instructor. Volunteer roles include farm crew, garden crew and seasonal sales of produce and compost. Participation may lead to independent volunteer or vocational opportunities here or elsewhere. If you are new to Pony Power, an interview is required. Limited times available.

Quantity of SV

Garden Assisted Learning: $480 for 12 lessons
Lessons are 30 minutes with 1:1 instruction. Offered in the afternoons, Monday through Thursday. Activities will vary from week to week and be based on the growing season responsibilities and participants' interests and goals.

Quantity of GL

Total Cost $

Participant Information

Participant First Name

Participant Last Name

Primary Email for Booking and Scheduling

Date of Birth

Is the Participant over 21 years old?

YesNo

Participant Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Please let us know your goals:

Participant Demographic Information

Thank you for taking the time to provide the following information. This section is designed to help us better understand the diverse community we serve. The data collected will be used solely to seek support for our services and programming. Rest assured, all personal information provided will be kept strictly confidential and will not be shared with any external parties.

Gender:

MaleFemaleNon-binaryPrefer not to say

Race/Ethnicity (select all that apply):

African American/BlackAsianCaucasian/WhiteHispanic/LatinoNative American/Alaska NativeNative Hawaiian/Pacific IslanderPrefer not to say

Primary Language Spoken at Home:

EnglishSpanishKoreanRussianOther

Please describe

Household Income for participant:

Less than $25,000Less than $25,000$50,000 - $74,999$75,000 - $99,999$100,000 - $149,999$150,000 or morePrefer not to say

Education Level of participant:

Less than high schoolHigh school diploma or equivalentSome college, no degreeAssociate degreeBachelor’s degreeGraduate or professional degreePrefer not to say

Employment Status of participant:

Employed Full-TimeEmployed Part-TimeUnemployedStudentRetiredPrefer not to say

Current Living Situation:

Own HomeRented HomeGroup HomeSenior HousingSupportive HousingSheltered/Unhoused

Transportation Method to Our Facility (select all that apply):

Drive SelfRide from Family/CaretakerPublic TransportationRideshare Service (Uber, Lyft, etc.)CarpoolWalkingBiking

Participant Details

Height

Weight

Communication

Please describe:

Ambulation

Please describe other ambulatory needs:

What medications is the participant currently taking, including over-the-counter medications?

Does the participant have a history of seizures? If so, please describe.

Please describe the participant’s physical abilities (i.e. sitting, standing, fine motor skills, head/neck control, etc.).

Please describe the participant’s social structure and interests (i.e. Work/school, leisure interests, relationships/family structure, support systems, companion animals, fears/concerns, etc.)

Does the participant have any diagnoses or history of medical conditions? If so, please search for/select them in the box(es) below.

Select diagnosis or medical condition below

Please describe details about the diagnoses/history of medical conditions:

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Cell Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Relationship to Participant

Are you the participant's Emergency Contact?

YesNo

Emergency Contact Information

First Name

Last Name

Cell Phone

Relationship to Participant:

Scheduling Preferences

During the school year, services are offered Sunday-Thursday. Participant lessons are scheduled for the same day and time for an entire semester. Please indicate your preferences here. If you would like to request specific day(s) and time(s), please leave details in the comment box below.

I would like to keep my same day & time.I can only attend on SundaysWeekday afternoons only

Scheduling comments:

Payment

How will you be paying for lessons? If you select financial aid, please see the scholarship form in the Programs section on our website.

Self-payFinancial aid (registration will be considered only once scholarship application has been received)DDD (over 21 years old)Valley Kireker CenterHUMC referralThird-party Payer (ex. School districts, CMOs like Bergen's Promise or Circle of Care, foundations)

Self-Pay Details

I would like to:

Pay in full nowPay a $150 deposit now and pay the balance within 2 weeksAll credit/debit payments are subject to a 3% processing fee.

Total Payment Due Now: $

This includes a 3% credit/debit processing fee.

Total Payment Due Now: $

This includes a 3% credit/debit processing fee.

Balance Due: $

DDD Information

DDD Support Coordinator First Name

DDD Support Coordinator Last Name

Email of DDD Support Coordinator

Phone Number of DDD Support Coordinator

Third-Party Billing Information

CMO Case Manager and/or Billing Contact First Name

CMO Case Manager and/or Billing Contact Last Name

Email of CMO Case Manager and/or Billing Contact

Phone Number of CMO Case Manager and/or Billing Contact

Credit Card Information

Credit Card Number

CVV

Expiration Month

Expiration Year

Name on Card

Cardholder's Email

Important Policies & Releases

POLICIES

PAYMENT

SELF-PAY: By submitting a registration, you are committing to the fees for the program(s) you selected. You may either pay in full or pay a deposit of $150 at the time of registration.

Payment is due in full within 2 weeks of submitting your registration. Payments are refundable ONLY if we are unable to fulfill your initial schedule request. All payments are nonrefundable once a schedule has been agreed upon. We are unable to make changes to days/times once the schedule is set.

FINANCIAL AID: Your scholarship application must be submitted at the time of registration. Registrations with Financial Aid selected will not be considered without a complete scholarship application including supporting documentation. Scholarship applications submitted without supporting documentation will not be considered. Click HERE for the scholarship application available on our site under Our Services.

All payments are nonrefundable once a schedule has been agreed upon and financial aid has been approved. We are unable to make changes to days/times once the schedule is set.

DDD: Upon submitting a registration, participant families are ultimately responsible for payment of all fees for the services for which they have registered. If DDD does not cover all lesson fees for any reason, participant families are responsible for payment in full and will be billed. Once you register and a schedule is agreed upon, we will provide your support coordinator with an invoice. At this point, you are committed to a spot and there will be NO reversal of billing (aka refund). This policy is the same for all participants regardless of method of payment.

Your support coordinator should set up the service plan as a single payment that can be billed for the first the week of lessons. Please share this registration link with your support coordinator as it provides them with all of the necessary information to create the service plan. Registration is only complete once Pony Power receives your approved service plan. While we are asking for the contact information of your support coordinator, it is the responsibility of the participant family to initiate, follow up and ensure that Pony Power is provided an approved service plan for each semester.

New as of July 1, 2024: When you register, we are holding a spot for your participant on good faith. Should you drop out less than 30 days prior to the start of a semester, you may lose access to priority registration for the following semester.

Third-party Payment by CMOs, school districts, foundations or any other resource covering the cost of services: If you have been referred by a CMO such as Bergen's Promise or Circle of Care, please include contact information for your case manager or the person responsible for billing at your school district or the foundation funding your services at Pony Power. In order to hold a spot for you, we will need to receive payment or written confirmation that fees for your services will be covered by the third party payer within 7 days of registration.

ABSENCES

Program dates are posted on the calendar at the bottom of our home page: ponypowernj.org
Lessons will be held rain or shine.
We are not able to offer discounts, makeups or refunds for absences, planned or unplanned.
Please call, text or email Pony Power to notify us of an absence as it affects our volunteers who help in lessons.
If you or your child is ill, please stay home for to ensure your safety and that of our volunteers and staff.
Should Pony Power cancel lessons, it is our responsibility to make the lesson up at a later date or provide a refund.
Regular attendance considerably increases the benefits for participants. More than two absences per semester may result in the loss of priority registration status for future semesters.

PHYSICIAN STATEMENT

Required only for those enrolled in Therapeutic or Sibling Riding: The physician statement form must be completed annually to be eligible for riding. If you are new to Pony Power, you will need to provide us with the completed form within 30 days of registration. If you are a current rider with Pony Power, our staff will let you know when your physician statement needs to be updated. Forms are available on our website under Policies and Forms.

SEVERE WEATHER

Pony Power will determine the need for canceling lessons due to storms or extreme temperatures. In the event of a last-minute decision to cancel, we will make every effort to reach you by text, email and/or phone call at least one hour prior to the scheduled lesson. If you are unsure of the weather conditions and have not heard from Pony Power prior to leaving for your lesson, please call: 201-934-1001.

Pony Power Therapies will not allow participants to ride in the event of thunder and lightning or extreme heat. In the event of a storm or extreme heat, participants scheduled to ride will then work with their instructor on our horsemanship curriculum in one of the barns.

Pony Power Therapies reserves the right to suspend riding and/or horse-assisted learning activities if sessions are deemed unsafe/inappropriate for any reason.

REQUIRED APPAREL

All participants must wear closed-toe shoes (sneakers or boots) and dress for outdoor temperatures; long pants are recommended. All riders must wear long pants and have their own ASTMI-certified riding helmet. Helmets are available locally at Ramapo Saddlery in Mahwah, 201-512-1418 or Equitique in Stockholm, 973-864-2693.

By signing, I acknowledge that I have read and agree to the payment, absences, paperwork, severe weather and required apparel policies as stated above.

I have read and agree to the above policies.

Initial

RELEASES

The above participant would like to participate in the Pony Power Therapies, Inc. program. I acknowledge the risks and potential for risks of horseback riding. However, I feel that the possible benefits to my self, my son, my daughter, my ward are greater than the risk assumed. I hereby, intending to be legally bound, for myself, my heirs and assigns, executors or administrators, waive and release forever all claims for damages against Pony Power Therapies, Inc., its Board of directors, instructors, therapists, volunteers and/or employees for any and all injuries and/or losses I may sustain while participating in Pony Power Therapies, Inc. By checking below, I agree to the terms.

I agree

Initial

I consent to and authorize the use and reproduction by Pony Power Therapies of any and all photographs and any other audio/visual materials taken of me for promotional material, educational activities, exhibitions or for any other use for the benefit of the program.

I doI do not

Initial

Fall 2024

Registration

Pony Power Therapies

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