Pathfinders After School Application

School Year*

Days of the Week Applying for*

Today's Date*

Child's Name*

Cild's Date of Birthh*

What school does your child attend?*

Parent/Guardian 1 Name*

Parent/Guardian 2 Name*

Home Address*

Parent/Guardian 1 Email*

example@example.com

Parent/Guardian 2 Email

example@example.com

Parent/Guardian 1 Phone Number*

Area CodePhone Number

Parent/Guardian 2 Phone Number

Area CodePhone Number

Referred By

What do you wish your child to gain from being in a Nature After School Program?*

How often does your child spend in free play in a natural setting (i.e. forest, meadows, creeks, non manicured environment or neighborhood park?)*

How would you describe your connection to nature?*

Are you comfortable with your child getting muddy and dirty? (Please note, yourchild WILL get dirty and your response to this is important to whether they feel ok with being involved in the play that happens at Pathfinders.)*

What are your thoughts about allowing your child to be in the world of imagination and story?*

What concerns might you have about nature or an outdoor classrom?*

What is pleasurable and easy for you with regard to your child’s personality?*

What is challenging for you with regard to your child's personality?*

How do you and/or your family deal with conflict and discipline?*

Does your child see, or have they seen, a therapist, of any kind (i.e. physical, emotional, occupational, etc.)? If so, what were the reasons for this and how does this affect your child at the current time?*

Does your child have any known allergies? If yes, what are they?*

Is there anything else you would like to share about your child?*