Summer Morning
Groups Registration

SUMMER MORNING PROGRAMS

PROGRAM INFORMATION

Forest Families (Summer Half-Day), July 14-17, 9:30AM-12:30PM:

$300 for the first child, $240 for each additional child. All children must be between the ages 1.5-5 years old. Children can discover the wonders of farm life by exploring our half-acre vegetable garden and interacting with our chickens, goats, ponies and sheep. Parents or caregivers stay with the younger child(ren) while supporting the older child(ren) as needed.

Farm in Motion (Summer Half-Day), Aug 4-7 OR Aug 11-14, 9AM-12PM:

$630 for the first child, $500 for each sibling. Half-day summer program for children with or without disabilities, mental health challenges, and life-threatening or life-limiting diseases. All participants must be between the ages of 5-12. Group activities will include riding, horse-care, farm education and nature activities.

Note: If your participant requires an 1:1 aide, a parent or caregiver will have to stay onsite for the duration of the program.

SELECT YOUR SERVICE(S)

Choose "1" in the quantity field for your desired program(s) from the options below.
One participant per registration form. Siblings must be registered on separate forms.
To register a sibling, you must have at least one other child enrolled in the same week of the program.

Forest Families, July 14-17: $300

Quantity of FB

Sibling Forest Families, July 14-17: $240
To be eligible for the sibling rate, at least one other child must be enrolled in Forest Babies Summer Half-Day for July 14-17.

Quantity of SibFB

Farm in Motion, Aug 4-7: $630

Quantity of FiM1

Sibling Farm in Motion, Aug 4-7: $500
To be eligible for the sibling rate, at least one other child must be enrolled in Children's Summer Half-Day for Aug 4th-7th.

Quantity of SibFiM1

Farm in Motion, Aug 11-14: $630

Quantity of FiM2

Sibling Farm in Motion, Aug 11-14: $500
To be eligible for the sibling rate, at least one other child must be enrolled in Children's Summer Half-Day for Aug 11th-14th.

Quantity of SibFiM2

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

How did you find out about Pony Power?

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 and to ensure that we are effectively meeting the needs of all our participants. The data collected will be used solely to improve 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

Please describe

Race/Ethnicity (select all that apply):

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

Please describe

Primary Language Spoken at Home:

EnglishSpanishRussianKoreanOther

Please describe

Household Income for participant:

Less than $25,000$25,000 - $49,999$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.).

How will the participant get to their lessons? (i.e. family/caregiver, ride share such as Uber/Lyft, car service, or driving themselves).

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

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)Third-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 weeks or the start of the semester, whichever comes first.All 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: $

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 nonrefundable deposit of $150 at the time of registration.

Payment is due in full within 2 weeks of submitting your registration or by the start of the semester, whichever comes first. 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. Scholarship applications submitted without supporting documentation will not be considered. Click HERE for the scholarship application.

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.

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 schedule on our program page:
https://www.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 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.

PHYSICIAN STATEMENT

Required only for those enrolled in Farm in Motion: 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 Forms and Policies.

SEVERE WEATHER

Pony Power will determine the need for canceling programming 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

Summer Morning Groups Registration

Pony Power Therapies

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Summer Morning
Groups Registration