Application Form

Gender MaleFemale

Current Grade 4567Other

Interested in a group in:  East Bay Marin San Francisco Sonoma County Other

Please share some information about your child which would be helpful for Leaders to know:

What do you hope your child will get out of Stepping Stones?

In what areas does your child struggle?

What experience does your child have working in groups or being part of a team?

What do you see as your child’s greatest strengths or assets?

Are there any medical, developmental, or behavioral issues that we should be aware of?

Is there anything else you would like to tell us about your child?

Family Status:---Parents married and living togetherParents divorcedParents separatedSingle parentParent deceasedOther
Are you aware of the program schedule commitments?  Yes No
Do you anticipate your family will need tuition assistance?  Yes No

Other children in family:

Your Contact:

Parent/Guardian #2:

Parent/Guardian #1:

Parent/Guardian #2:

Household One Address:

Household Two Address: