Participant Application

Participant Application
We appreciate your cooperation in answering the questions in this form as fully as you can. When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you!

** Allow about 15-20 minutes

** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost.

** Minimum age is 11

This information will be kept strictly confidential. Your personal information is collected for the purpose of supporting you properly and for administrative purposes. It will not be disclosed for other purposes without your consent.
Who is filling out this form?
Who is filling out this form?*
Parent/Guardian Details.
Parent name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Support Worker details.

Please enter any support worker details
Support worker Name

First NameLast Name
Email
example@example.com
Company you work for?
Phone Number
Please enter a valid phone number.
ABOUT YOU
Name of Participant*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Minimum age is 11
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*
What School do you attend*
Let us learn more about your interest and support in doing this type of program
We would love to learn some more about you to allow us to better support you in this process. Please write a short response to each of the following questions.
Have you visited The Funky Farm before?*

YesNo
Do you like animals?*

YesNo
What is your favorite animal?*
Are you scared or unsure of any animals? If yes please tell us what animals. *
Do you have any pets? If yes please tell us what you have.
What animal here at MPWP would you love to work with?*
Have you worked or volunteered with animals before?*

YesNo
If you answered yes to the above question, please explain where and what skills you may have acquired.
Do you enjoy the outdoors?*
Can you work with others?*

YesNoUnsure
What do you like to do?*
What don't you like to do?*
Tell us about your strengths, hobbies, interests. What do you like to do for fun and relaxation?
Diagnosis and Medical
Please be honest in the section below, as it will not necessarily preclude you from working with us, it will simply involve clarifying which approaches might be best for you, or what work we need to do before a session. Dishonesty will put you and the facilitators at risk, and will not lay the proper groundwork for you to have a safe and energetically clear journey.
Formal diagnosis - Primary*
Formal diagnosis - Secondary
Mobility?*

IndependantAssistWheelchairWalking frameOther
Communication.*
If other, Please let us know
Are you restricted with arm or hand movements?*
If yes, Please provide details.
Are you hearing impaired?*
If yes, Please provide details including if you sign.
Are you visually impaired?*
If yes, please provide details.
Please list any allergies that you have:*
If yes, please provide details
Does the participant need an EpiPen or autoinjector?*

YesNo
Which of these physical symptoms do you experience?*

Panic attacksQuick temper/irritabilityStomach upsetBrain FogHeadaches/migrainesFatigue/DizzinessNoneOther
Do you have a full time support worker?*

YesNo
If you answered yes, please provide more details.
Do you take regular medication?*

YesNo
If yes, please provide more details
Mental Health, Stress, Anxiety & Trauma History
Have you ever been diagnosed by a psychologist or psychiatrist with a ‘mental illness’ or DSM disorder (such as major depression, borderline personality disorder etc)? If so, what was the diagnosis and when did it occur?
Please list any current significant mental health issues:
Do you have anxiety?*

YesNo
If yes, What are your triggers?
What are your coping strategies?
I would rate my current stress/anxiety on a scale of 0-10 (10 being high)

if 0 don't click any stars
Please comment on the most current significant source(s) of Stress and Anxiety
Do you get tired easily?*

YesNo
Are you able to concentrate for more than?*

10min20min30min1hrOther
Are you able to follow directions?*

YesNo
Please provide any further details about your stress/anxiety and trauma history that you feel may be relevant.
Program Goals
Please describe your goals for the future:
What are the main things you are wanting to achieve in the 12 week program?
Are you hoping to get a job in the future?*

YesNoUnsureOther
If yes, what area of work are you looking for?*

Farm animal industryWildlife industryEquineAgricultureRetailFactoryAdmin officeSalesIT HospitalityEntertainmentApprenticeshipConstructionConservationOutdoorsIndoorsOther
Anything else you think we should know about you so we can provide you with the best support possible.
My signature below affirms that I have answered the above as truthfully and completely as possible:
Today's Date*

DayMonthYear
Signature (hold/click and sign with cursor)*

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Participant Application

Who is filling out this form?

Parent/Guardian Details.

Support Worker details.

ABOUT YOU

Let us learn more about your interest and support in doing this type of program

Diagnosis and Medical

Mental Health, Stress, Anxiety & Trauma History

Program Goals

My signature below affirms that I have answered the above as truthfully and completely as possible: