CULTIVATING HOPE Participant Application

CULTIVATING HOPE Participant Application

Memory Lane Farm, Inc. 8640 Heritage Dr., Marshfield WI 54449
The following application is to be completed for all Memory Lane Farm Cultivating Hope program participants. This form has been designed to provide necessary information to our mentor staff before our initial session in order to make the most productive and efficient use of our time together. All information provided is strictly confidential and will not be released without written consent.
GENERAL CONTACT INFORMATION
Today's Date: *

Month Day Year
Date
Name of Applicant: *
Is applicant: *

Adult Minor
Desired Program: *

Cultivating Hope
Address: *
City *
State *
Email: *
example@example.com
Phone: *
Emergency Contact Name: *
Emergency Phone: *

Area Code Phone Number
Relationship: *
Referral source name: *
Who suggested this program to you?
Referral relationship (i.e. teacher, counselor, pastor, professional): *
MINOR’S INFORMATION
Child's Last Name:
Child's First Name:
Nickname:
Parent(s)/Guardian Legal Name:
Age of Child:
Grade of Child:
Current grade
Birthday:
PROGRAM INFORMATION

(completed by participant or parent/guardian)
How can you, your child or family benefit from this program (be as specific as possible): *
Do you or your child have one or more of the following concerns:

Anxiety Depression Grief Confidence Issues Social Skill Concerns
Of those listed above, which one concern should be addressed in our program that can be resolved or worked on in our 12-week program? *
Are there issues that you feel our leadership team should be made aware of (medical, allergies, emotional, behavioral, physical limitations, etc.) *
Are you or your child able to identify concerns, and ready to make to work toward making changes in life?

No, not at this time Yes!!
REQUIREMENTS FOR PARTICIPATION
We understand that this is a farm-based program whereby participation is necessary. I attest that I/my child want to participate and understands the general goals of the program.
LIABILITY WAIVER
All guests, participants and volunteers are required to sign a Liability Waiver and photo release waiver in order to participate in our programs, as required by our insurance. Waivers will be provided at the time of applying for our program. Waivers are kept on file for one calendar year.
SCHEDULING
Memory Lane Farm's Cultivating Hope Mentoring program is a popular and invested program where staff and volunteers selflessly give their time to serve you/your family. If you are more than 10 minutes late for your scheduled session for any reason, that time may be repurposed. A phone call or text (not email) to 715.897.7187 is required for any cancellation or tardiness.

Missed sessions will not be rescheduled. If you are late or miss two or more sessions in a season, the spot MAY be forfeited for the remainder of the current session season.
COMMUNICATION
All participant application and personal information is considered confidential and only information critical to the success of the participant will be shared with Session Leaders or Mentors.

The staff and volunteers of Memory Lane Farm come with many years of combined mentoring, and life experience and desire to play an important and impactful role in the development of our participants.

Staff and volunteers of Memory Lane Farm, Inc. are not counselors, therapists or are authorized to offer any professional advice. We, however are happy to offer resources for families and participants.

I have read and understand the Participant and Parent/Guardian Guidelines as stated above:
Participant/ Parent/Guardian Printed Name *
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

CULTIVATING HOPE Participant Application

GENERAL CONTACT INFORMATION

MINOR’S INFORMATION

PROGRAM INFORMATION

REQUIREMENTS FOR PARTICIPATION

LIABILITY WAIVER

SCHEDULING

COMMUNICATION