Dunegrass Healing 2022 Application Form Question Title * 1. Contact and Background Information Applicant's Name Name of the applicant's parent or guardian Address Parent or guardian's email Parent or guardian's phone (preferably cell) Is it alright to contact you by text? Age of applicant Gender of applicant Applicant's school Applicant's grade Does the child have an email and access to internet? If so, please provide the email address. With the parent or guardian's permission, if accepted into the program, we will email intake forms to both the child and parent or guardian to be filled out separately. Question Title * 2. Briefly describe areas where the applicant is struggling socially and/or emotionally. For example, insecurity, low self-esteem, anxiety, depressive feelings, or other areas. Question Title * 3. Please rank on a scale of 1 (not at all relevant) to 7 (extremely relevant) how the applicant struggles in the below areas. 1 2 3 4 5 6 7 Anxiety/Worry Anxiety/Worry 1 Anxiety/Worry 2 Anxiety/Worry 3 Anxiety/Worry 4 Anxiety/Worry 5 Anxiety/Worry 6 Anxiety/Worry 7 Depression/Sadness Depression/Sadness 1 Depression/Sadness 2 Depression/Sadness 3 Depression/Sadness 4 Depression/Sadness 5 Depression/Sadness 6 Depression/Sadness 7 Low self-esteem Low self-esteem 1 Low self-esteem 2 Low self-esteem 3 Low self-esteem 4 Low self-esteem 5 Low self-esteem 6 Low self-esteem 7 Anger Anger 1 Anger 2 Anger 3 Anger 4 Anger 5 Anger 6 Anger 7 Physical aggression, such as hitting or throwing things Physical aggression, such as hitting or throwing things 1 Physical aggression, such as hitting or throwing things 2 Physical aggression, such as hitting or throwing things 3 Physical aggression, such as hitting or throwing things 4 Physical aggression, such as hitting or throwing things 5 Physical aggression, such as hitting or throwing things 6 Physical aggression, such as hitting or throwing things 7 Perfectionism Perfectionism 1 Perfectionism 2 Perfectionism 3 Perfectionism 4 Perfectionism 5 Perfectionism 6 Perfectionism 7 Dislike of self Dislike of self 1 Dislike of self 2 Dislike of self 3 Dislike of self 4 Dislike of self 5 Dislike of self 6 Dislike of self 7 Self harm, such as cutting Self harm, such as cutting 1 Self harm, such as cutting 2 Self harm, such as cutting 3 Self harm, such as cutting 4 Self harm, such as cutting 5 Self harm, such as cutting 6 Self harm, such as cutting 7 Suicidal thoughts Suicidal thoughts 1 Suicidal thoughts 2 Suicidal thoughts 3 Suicidal thoughts 4 Suicidal thoughts 5 Suicidal thoughts 6 Suicidal thoughts 7 Suicide attempts Suicide attempts 1 Suicide attempts 2 Suicide attempts 3 Suicide attempts 4 Suicide attempts 5 Suicide attempts 6 Suicide attempts 7 Question Title * 4. What is the applicant hoping to gain from this program? Question Title * 5. What is the applicant’s interest level regarding their participation in Dunegrass Healing’s summer program? Low Medium High Question Title * 6. Are there any health issues that would prevent or hinder your participation in physical activity? If so, please explain. Question Title * 7. Financial Assistance: The cost of the program is $250. Please indicate if you need partial scholarship to be able to participate in the program. Please note there are limited scholarship funds available and while we hope to provide assistance to all those in need, that may not be possible. Please give your best estimate of scholarship amount needed to participate in this program. $100 $125 $150 $175 $200 Other amount (please specify) Question Title * 8. If requesting a scholarship, please tell us about your financial needs. Done