contact us

Use the form on the right to contact us.

You can edit the text in this area, and change where the contact form on the right submits to, by entering edit mode using the modes on the bottom right.

Russell Cave Road
Georgetown, KY, 40324
United States

(859) 340-4289

A 501(c)(3) non profit that serves struggling youth in Lexington, Ky. 

Participant Application

Participant Application Form

Please fill out the form in it's entirety. A "*" indicates a required field and must be filled out before submitting the application. We serve youth ages 12-18 who struggle with emotional, spiritual, behavioral, and related issues. This application is for these individuals to receive mentorship and therapeutic horsemanship services as an effort to increase their quality of life. 

*
Participant Name *
Participant Name
Address *
Address
Phone *
Phone
Signature *
Signature
I hereby consent for the above information to be maintained in the SHEM database so that I may receive information about the program.
Why are you applying for this program? What would you like the participant to accomplish by participating?
Emergency Medical Information
Physician's Name *
Physician's Name
Persons to be contacted in case of Emergency (at least two) *
Persons to be contacted in case of Emergency (at least two)
Contact 1
*
*
Contact 2
*
Contact 3
Participant Medical History
Please indicate current for past needs, concerns, or procedures in any of the following areas as indicated by a check. If yes, please comment.
Signature *
Signature
To the best of my knowledge the medical history is true and accurate:
Demographic Information
SHEM is a 501(c)3 non-profit organization supported by donations. We are frequently required to provide anonymous demographic information when applying for grants and other funding. Your help is greatly needed. Every participant must complete the the following information. This information will be kept confidential and you may return this page separate from other registration information. Please remember that participant fees cover a very small percentage of the costs to provide services. An important way you can help with fundraising is to provide SHEM with needed information to apply for grants and funding.
Your session fee will be based off of annual household income.
Needed for grant applications.

Thank you for submitting an application for services from SHEM. Submitting an application does not guarantee services. We look forward to meeting and serving you.