Sundance Therapy Outdoor Explorers

Reserve Your Spot

Reserve Spot

Participant Name First Last

Participant Age Please tell us about any additional support needs (a member of our team will contact you to discuss)

Parent/Legal Guardian Name First Last

Email Phone

Select Your Sessions

You may select multiple Sessions. You can also select Before or After Care for each session.Sessions A & B | June 3-5 2024 – Fun on the FarmSelectSession A (9:30am- 12pm)Session B (12:30pm – 3pm)Session A and B (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Sessions C & D | June 10-12, 2024 – Animal DetectivesSelectSession C (9:30am- 12pm)Session D (12:30pm – 3pm)Session C and D (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Sessions E & F | June 19-21, 2024 – Craftivism w/ Art GarageSelectSession E (9:30am- 12pm)Session F (12:30pm – 3pm)Session E and F (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Sessions G & H | July 8-10, 2024 – Wonder GardensSelectSession G (9:30am- 12pm)Session H (12:30pm – 3pm)Session G and H (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Sessions I & J | July 17-19, 2024 – Makers & BuildersSelectSession I (9:30am- 12pm)Session J (12:30pm – 3pm)Session I and J (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Sessions K & L | July 22-24, 2024 – Nature’s HarvestSelectSession K (9:30am- 12pm)Session L (12:30pm – 3pm)Session K and L (9:30am – 3pm)

Before/After Care AM Care (9am-9:30am) PM Care (3pm – 3:30pm)

Total

Payment

Please select whether you will be paying yourself or requesting funding by your Case Management Agency. Regardless of your choice, you will be charged a non-refundable $1.00 Reservation Fee to reserve your selected sessions while the availability of a spot and/or approval of funding is determined.

How will you be paying for the sessions selected?Please select whether you will be paying yourself or requesting funding by your Case Management Agency. Self Pay with Credit Card Case Management Funding Request

Please ConsentI authorize the payment of $1.00 (unrefundable) to reserve the selected sessions while availability is being determined. If approved, I understand I will be notified and my credit card will be charged the full amount. I have read and agree to the Terms and Conditions I agree to the terms below.

For Families Requesting Developmental Pathways or RMHS Funding Only

Select Your Case Management Agency Developmental Pathways Rocky Mountain Human Services Other CMA (Please List)

Other CMA

Is the participant on a state disability waiver? Yes No

If Yes, what waiver does the participant currently have? Case Manager Name: Case Manager Email: Case Manager Phone #:

HiddenI authorize the payment of $1.00 (unrefundable) to reserve the selected sessions while my funding request is processed. Yes

HiddenI agree to send a provided invoice and W9 to the above listed Case Manager within 2 business days to request the funding. Yes

HiddenI have read and agree to the Terms and Conditions Yes

Please ConsentI authorize the payment of $1.00 (unrefundable) to reserve the selected sessions while my funding request is processed. I agree to send a provided invoice and W9 to the above listed Case Manager within 2 business days to request the funding. I have read and agree to the Terms and Conditions I agree to the terms below.

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