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Field Trip Application Form

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Application to Participate - Kids Healthy Outdoors Challenge 2019-2020

Please only submit one application per school. Review all information and expectations on the KHOC page on the EBRPD website before applying. You’ll need to have available the information on the following pages before applying online.

1. If you are not a third-grade teacher,you are ineligible for KHOC.

2. If you have participated in KHOC three or more years in the past,you are ineligible.

1. Check this box to confirm that you are a third-grade teacher.

2. I have not participated in KHOC three or more years in the past.

* School Name

* School District

* School Address

* Principal Name

* Principal Phone Number

* Principal e-mail address

About Your School: (Please complete the following based on the most recent available school year. Enter a whole numeral in each slot):

* 1. Total Enrollment

* 2. Percent of students eligible for Free and Reduced-Price Lunch (%)

3. Breakdown of student body by Race and Ethnicity
(Enter a whole numeral in each field, not the percent sign. Make sure your responses add up to 100)

* Latino %

* African American %

* Caucasian (non-Hispanic) %

* Asian %

* Pacific Islander %

* Native American/Alaska Native %

* More than One Race %

* Other %

* 4. Percent of students who are English as a Second Language (ESL) %

* 5. List the most common languages spoken by students in your school

* Type of School (Select one)

Applicant(s) Information: (Third Grade Teachers information; identify your Lead Teacher in section 1)

Lead Teacher/Teacher 1:

* 1. Name: Lead Teacher / Teacher 1

* 2. Phone
(Please provide the phone number where you can most easily be reached.)

* 3. Email
(Please provide the e-mail address where you can most easily be reached.)

* 4. Approximately how many students will you have in your classrooms this year? (Enter a whole numeral)

* 5. How many years have you been an educator? (Enter a whole numeral)

* 6. How many years have you taught third grade? (Enter a whole numeral)

* 7. How experienced and comfortable are you in leading classroom activities outdoors? (Please select one)

Teacher 2

1. Name: Teacher 2

2. Phone
(Please provide the phone number where you can most easily be reached.)

3. Email
(Please provide the e-mail address where you can most easily be reached.)

4. Approximately how many students will you have in your classrooms this year? (Enter a whole numeral)

5. How many years have you been an educator? (Enter a whole numeral)

6. How many years have you taught third grade? (Enter a whole numeral)

7. How experienced and comfortable are you in leading classroom activities outdoors? (Please select one)

Teacher 3

1. Name: Teacher 3

2. Phone
(Please provide the phone number where you can most easily be reached.)

3. Email
(Please provide the e-mail address where you can most easily be reached.)

4. Approximately how many students will you have in your classrooms this year? (Enter a whole numeral)

5. How many years have you been an educator? (Enter a whole numeral)

6. How many years have you taught third grade? (Enter a whole numeral)

7. How experienced and comfortable are you in leading classroom activities outdoors? (Please select one)

Teacher 4

1. Name: Teacher 4

2. Phone
(Please provide the phone number where you can most easily be reached.)

3. Email
(Please provide the e-mail address where you can most easily be reached.)

4. Approximately how many students will you have in your classrooms this year? (Enter a whole numeral)

5. How many years have you been an educator? (Enter a whole numeral)

6. How many years have you taught third grade? (Enter a whole numeral)

7. How experienced and comfortable are you in leading classroom activities outdoors? (Please select one)

By submitting this application, you are confirming that you meet the eligibility requirements for the KHOC program and that you agree to meet the expectations for participation in KHOC. Any questions or comments should be sent to khoc@ebparks.org.

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