Name: Special Needs Family Fun Day
Start: 2019-04-27T12:20:00-04:00
End: 2019-04-27T15:30:00-04:00
Location: Quantum Leap Farm

Are you current or former military?*

Yes
No

If you are current or former military and interested in our Warrior Mission: At Ease Retreats, please complete our full detailed application on the Warrior Mission: At Ease page Thank you! Click here for application page.

Applicant's Name*

First Last

Age of Applicant*

Parent/Caregiver Name*

First Last

Phone Number*

Email Address*

Enter Email Confirm Email

Program of Interest*

Therapeutic Riding
Occupational Therapy
At EASE (Equine Assisted Self Exploration)
Warrior Mission: At Ease Retreat
W.O.W. (Women of Warriors) Retreat
Kinesthetic Therapy
Family Fun Days

Please see Services page for more information on programs.

Waiting List**

Due to high demand, our Therapeutic Riding Program and Occupational Therapy Program are on a 1-year waiting list. Please check above regarding how you'd like to move forward with this program. We're very sorry for this inconvenience.

Please add me to the waiting list.
That's ok, please contact me anyways. I have additional questions.

Special Need, Disability, Injury or Primary Concern*

There is currently a waiting list to receive services from Quantum Leap Farm. After filling out this form, someone will contact you soon with more information.

Consent*

I consent to my submitted data being collected and stored.

Email

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

Contact Us

Quantum Leap Farm, Inc.

813.920.9250

813.920.2124

10401 Woodstock Road
Odessa, FL 33556-5017

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Special Needs Family Fun Day

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