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| Date of Birth: |
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| Grade you will be in Fall 2012: |
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| School |
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| Rate the following on a scale of 1 to 5 with 5 being the highest: |
| Your interest in nature and science
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| Your interest in the outdoors |
| Your interest in fishing |
| Your interest in hiking |
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| How do you feel about being away from family and friends for almost a week? |
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| List outdoor activities, and how often, you have participated in with your family (such as: picnics, camping trips, hiking trips, fishing, etc.). |
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| I understand that this is an outdoor activity, which involves sleeping in a platform tent, hiking on mountain trails, wading in mountain streams and being with others who may be very different from me. I understand there are limited spaces in this program, therefore there is no guarantee that I will be selected to participate. |
| In lieu of signature, type names below. |
| Your name: |
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| Parent/Guardian |
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| If not initially selected, would you like to be placed on a waiting list? |
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| All applications must be received by March 1, 2012. You will be notified by e-mail or phone no later than March 15 regarding your selection status. |
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| T-shirt size: |
| Shoe size: |
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