2025 Care Farming Services Referral - Please complete all areas on this form. We cannot accept forms missing any information. Thank you.
Hillside's Care Farming Service is a five-day, farm-based camp 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 attend this program. Our Care Farming Service is made possible through the generosity of individual donors and private foundations. All fields must be completed in entirety. Contact information (phone/email is required). 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 sessions at Hillside Farms.
Child's Name
*
First Name
Last 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?
Yes
No
Please provide a description of the child's eligibility for this farm-based service
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Does the child have any of the following?
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Learning Disability
Behavioral issues/concerns
ADD/ADHD
None
Other
Does the child have daily support staff?
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yes
no
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?
*
yes
no
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)
*
Submit
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