Grounding Roots Virtual Learning

Grounding Roots Virtual Learning

Student Interest Survey
Parent or Guardian's Name*

First NameLast Name
Student's Name*

First NameLast Name
Student's Age*
Student's Grade*
Parent's E-mail*
Student's E-mail
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which Tribe is your student affiliated with?*
Is your student familiar with their cultural practices?*

Yes, Very involvedYes, a littleNot reallyNo, but wants to learn
If so, what do they enjoy participating in?
Does your student have an IEP or 504 plan?*

YesNo
If so, what types of accommodations are helpful?
Does your student have allergies?*

YesNo
If so, what is your student allergic to?
What is your student most interested in Learning? Please pick your top five*

BeadingWeavingIndigenizing ApparelSewingDrummingLanguageHistoryNutrition and WellnessDrawing and PaintingWood CarvingInstrument MakingDecolonized SystemsMoccasinsBagsLeather WorkRibbon WorkFeather WorkNecklaces and other Jewelry MakingAccessoriesOther
Are there other things not listed or any specific type of craft or content that your student is interested in learning?
Is your student interested in joining a peer talking circle?*

Tell Me MoreYesNoMaybeOther
Is your student interested in becoming a member of the Unci Maka/Na’ah Ili’i/ Mother Earth Rescue Team?*

Tell Me MoreYesNoMaybeOther
Is your student interested in Indigenous Based Educational Mentorship?*

Tell Me MoreYesNoMaybeOther
Which Virtual Platform do you like best?*

SeesawCanvasGoogle ClassroomZoomOther
Which DAYS are best for your student to participate in our classes or talking circles?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Which TIMES are best for your student to participate in our classes or talking circles?*
Is there anything else you'd like us to know about your student or family?
Should be Empty: