Field of Hope Resiliency Program

Shaping Resilient Youth

The goal of Field of Hope’s new Resiliency Center is to help the youth in our community be the
best versions of themselves, preparing and shaping them for their lives ahead. We will provide a
hot evening meal to ensure each of the youth in our program goes home with full stomachs. Our
program will include playing games, arts and crafts, physical activity in our full-size gym, basic
gardening skills, and outdoor activities. Most importantly, we want to teach our youth how to
build relationships and build a community network outside of a school setting with positive
mentorship. Recognizing that mental health, our environment, and our choices are the building
blocks of our future, we are dedicated to providing a solid foundation for our youth.

Complete the form below or access the PDF here.

Parent/Guardian 1 (Required)

Parent/Guardian 1 *

First

Last

Relationship *RelationshipMotherFatherGrandparentOther

If relationship is "other", please explain

Email *

Phone *

Preferred method of contact *

• Text
• Cell
• Email

Address *

Address Line 1

Address Line 2

City

OhioAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Employer *

Employer Phone

Parent/Guardian 2 (Optional)

Parent/Guardian 2

First

Last

RelationshipRelationshipMotherFatherGrandparentOther

If relationship is "other", please explain

Email

Phone

Preferred method of contact

• Text
• Cell
• Email

Address

Address Line 1

Address Line 2

City

OhioAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Employer

Employer Phone

Students Grades 6th, 7th, & 8th

Student 1 *

First

Last

Layout

Date of Birth *

School *

Participant of the after-school program? *

• Yes
• No

Address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Age *

Grade *7th6th grade7th grade8th grade

Gender *

• Male
• Female
• other

Phone *

Student 2

Student 2

First

Last

Layout (copy)

Date of Birth

School

Participant of the after-school program?

• Yes
• No

Address

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Age

Grade7th6th grade7th grade8th grade

Gender

• Male
• Female
• other

Phone

Transportation

Students attending the RVMS after school program can be transported by bus to Field of Hope at 5:00 pm. Transportation is available for students who live within a 5 mile radius of Field of Hope (11821 SR 160, Vinton, Ohio 45686)

Make Selection(s) Based on Transportation Needs *

• I can provide transportation to drop off my student at Field of Hope
• I have transportation to pick up my student at Field of Hope at 7:30 pm when the program ends.
• I need my student transported home from Field of Hope and live within a 5 mile radius.
• My student will ride the bus to Field of Hope from the RVMS after school program.

Signature *

Clear Signature

Date *

Medical and Emergency Contact Forms

Medical and emergency contact forms required once accepted into the program.

Submit

Questions?

Question? Reach out to Stephanie to learn more.

Call: (740)-245-3051 ext.122

Email: stephaniebobb@fieldofhope.life