• 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

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  • MINOR’S INFORMATION

  • PROGRAM INFORMATION

    (completed by participant or parent/guardian)
  • 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:

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