2025 Hillside Farms Care Farming Services Referral

Child's Name*

First NameLast Name

Child's Age*

Child's Grade*

School/District*

Parent/Guardian Contact Information (please provide name, phone, email)*

Referred By (name, relationship to child)*

Have you discussed your referral with the parent/guardian of the child?

YesNo

Please provide a description of the child's eligibility for this farm-based service*

Does the child have any of the following?*

Does the child have daily support staff?*

yesno

To the best of your knowledge, has the child ever been considered to be a safety risk to themselves or others? Is the child a flight risk?*

yesno

If yes, please explain.

Please type your referral*

Hillside's Care Farming Service is a five-day program open to children ages 6 through 14 who have experienced the loss of an immediate family member through illness, accident, homicide, or suicide. We also welcome children who are in foster care or who are experiencing life-changing circumstances due to divorce, adoption, or family addiction. There is no cost to the family. Referral does not guarantee registration as the number of participants is limited in order to provide an optimal experience for the children. Priority is given to children who have not previously attended our program.

Your contact information (name, title, phone, email)*

2025 Care Farming Services Referral - Please complete all areas on this form. We cannot accept forms missing any information. Thank you.