Program Name

Website

Address

City

State

State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaIdahoHawaiiIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

New Field New Field Please enter the names and contact information for up to 3 participants. Particpant 1

First Name

Last Name

Email Address

Phone

Mobile Phone

Please enter the names and contact information Please enter the names and contact information Particpant 2

First Name

Last Name

Email Address

Phone

Mobile Phone

Please enter the names and contact information Please enter the names and contact information Particpant 3

First Name

Last Name

Email Address

Phone

Mobile Phone

1. Describe your program (number of students, ages you serve, public school, private school, part day preschool)

2. Describe if/how outdoor play and learning are part of your current program.

3. Describe your current outdoor space.

4. What is working about your current outdoor space?

5. What are the biggest challenges of your current outdoor space?

6. Describe your ideal outdoor space and how it would work for children, families and staff.

7. List your short-term goals for your outdoor space.

8. Describe why you want to join this program.

9. Indicate the supports and resources you have in place. 9. Indicate the supports and resources you have in place. 9. Indicate the supports and resources you have in place.

People with energy and enthusiasm People with energy and enthusiasm Yes No not sure (staff, parents, community members)

People with time to help. People with time to help. Yes No not sure

People with related skills People with related skills Yes No not sure

People with related skills description

A system or requirement for parents to volunteer. A system or requirement for parents to volunteer. Yes No not sure (PTA, Co-op, etc.)

A safe, accessible outdoor space. A safe, accessible outdoor space. Yes No not sure

A grounds or playspace committee A grounds or playspace committee Yes No not sure

A committeed key person A committeed key person Yes No not sure (parent volunteer or staff member who will head up the effort)

If yes, please describe who it is and why they care.

Other resources you have: Other resources you have: Other resources you have:

Is your head decision maker supportive of this project? (Example: principal, program director) Is your head decision maker supportive of this project? (Example: principal, program director) Yes No Not Sure

Name and contact information of decision maker: Name and contact information of decision maker: Name and contact information of decision maker:

First Name

Last Name

Telephone

11. Additional information you would like me to know in considering you for a spot in the Create Outdoor Magic program.

BEFORE YOU SUBMIT BEFORE YOU SUBMIT Before you submit, I recommend you print this page. This is a long form, and we don’t want you to lose your work.