Application Phase 1

To nominate a child for the outdoor experience, please fill out the form and click submit. A representative will be in touch once the application is complete.

For additional information, please contact us at 281-477-6544.

Name *
Name
Child Name
Child Name
Physician Name
Physician Name
Physician Address
Physician Address
Physician Phone
Physician Phone
May we contact your family physician?
Parent/Guardian 1 Info
Parent/Guardian 1 Name
Parent/Guardian 1 Name
Parent/Guardian 1 Work Phone
Parent/Guardian 1 Work Phone
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Cell Phone
Parent/Guardian 1 Address
Parent/Guardian 1 Address
Parent/Guardian 2 Info
Parent/Guardian 2 Name
Parent/Guardian 2 Name
Parent/Guardian 2 Work Phone
Parent/Guardian 2 Work Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Cell Phone
Parent/Guardian 2 Address
Parent/Guardian 2 Address
Parent/Guardian 3 Info
Parent/Guardian 3 Name
Parent/Guardian 3 Name
Parent/Guardian 3 Work Phone
Parent/Guardian 3 Work Phone
Parent/Guardian 3 Cell Phone
Parent/Guardian 3 Cell Phone
Parent/Guardian 3 Address
Parent/Guardian 3 Address
Names and ages of sibling(s) living in the same household.
Parental Info
If parents divorced or separated, please list the parent the child lives with.
Legal Custody
Does the parent have legal custody?
If the child is not in legal custody of either parent, please explain the relationship of the guardian.
Race
Please share information about the race of the student.
Active Military
Is the child an active duty military dependent?
If yes, which branch of service?
Does the child have any physical limitations that must be accommodated during an outdoor adventure?
Outdoor Adventure Info
Has the child ever had an outdoor wish granted?
Hunter Safety Course
Has the child completed a hunter safety course?
If yes, please list state issued and certificate number of hunter safety course.
Please share how you heard about us.
If yes, please explain.
If approved, will the child and family be able to travel within 90 days? If the answer is "no", please explain:
Does the child have a Social Worker or Child Life Specialist? If so, please provide Name, Address, Phone and Email:
Waiver Of Liability
If the child is approved for the The Children's Refuge Outdoor Adventure, a parent or guardian will be required to sign a Waiver of Liability (Check box if you understand a waiver is required)?
Photo/Video Release
I give permission for photographs and video of my child to be shared on social media, promotions, or public use on websites and printed materials.
I am
Please share your relationship to the child.