Person Financially Responsible for Applicant

Address (if different than Applicant)

Amount Requested With This Application

Please describe your employment.

Please describe any sources of additional support.

Please describe the special circumstances that may affect your family’s ability to pay for a wilderness therapy program.

Anything else you might what us to know about you and/or your family? Please note that we do not have access to your wilderness program admissions application.

I have read this application thoroughly and certify that to the best of my knowledge all of the information is correct. I understand that funding can be denied if the application is incomplete or if the information is found to be misleading. I further recognize the importance of my personal involvement in the program and commit myself to do whatever may be required of me in order for this to be a successful experience for all those involved.

With the intention to provide helpful information and feedback to other families and their children in-crisis, it is very important to share our experiences with each other. By initialing above, we, mother and/or father or legal guardian and child or young adult—upon completion of a partnering wilderness therapy program, agree to be interviewed, and to provide written or video testimonial of my wilderness experience without compensation. Anonymity is respected if requested.