Back-To-Land Youth & Family Rolling Application

Thank you for your interest in our Back-to-the-Land Youth & Families Mentorship Program weekend camping retreat, taking place at our beautiful farm and forest land in Drain, Oregon. This immersive experience offers families the opportunity to engage in hands-on education in herbalism, forestry, and regenerative farming, while also participating in trauma-informed mentorship, family relationship-building, and emotional well-being practices. We are excited at the possiblity of your family joining us for a transformative weekend that fosters connection with nature, personal growth, and deeper family bonds.

Dates for 2026 retreat weekends will be announced in January 2026. Applicants will be offered spots in events with peers of similar age groups.

Here are some important things to know before you fill out your application:

Each family is allowed to register up to two youth participants (ages 6-17) for the retreat. All youth participants must be accompanied by a parent or legal guardian who will attend the retreat with them for the duration of the event. This ensures that families have the opportunity to connect and support one another throughout the retreat experience. It also ensures that there is a caregiver present to ensure the safety of the youth under their care.

Please note that while this retreat offers a supportive, safe, and enriching environment, it is not a therapeutic retreat and does not act as a substitute for therapy or mental health counseling. Our retreats are only aimed as a supplement to any existing wellness practices. If anyone attending this retreat is seeking psychological or physical health services, please pursue these through the appropriate medical channels.

The physical and mental health questions included in the application are intended solely to assess the capacity of each participant to participate safely in these community events and/or to identify any specific needs or considerations that may impact participants' experience if they were to join the retreat. All information provided is kept confidential and will only be shared with retreat mentors and support staff, as necessary, for the care and safety of the participant.

After you complete the application someone on our team will be in touch with you within a couple of weeks. Please remember that space is limited and that filling out this application, does not guarantee a spot at the event. However, we are planning to have ongoing camp weekends in 2026 and will include you on the mailing list for upcoming events if spots run out for the event of your choice.

With infinite gratitude,

The Liberation Pathways Team

First Youth Participant Name*

First NameLast Name

What do they prefer to be called?

Age of Youth Participant*

Youth Participant's Date of Birth*

Date

What are the Youth's pronouns?*

How do they identify (i.e. Latinx, Black, White, Cisgender, Queer, etc)?*

Second Youth Participant Name

First NameLast Name

What do they prefer to be called?

Age of Youth Participant

Youth Participant's Date of Birth

Date

What is the Youth's pronouns?

How do they identify (i.e. Latinx, Black, White, Cisgender, Queer, etc)?

Parent/Guardian Name (s)*

First NameLast Name

Parent/Guardian Pronouns?*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Contact Number.*

Please enter a valid phone number.

Email Address*

example@example.com

Name*

First NameLast Name

What do they prefer to be called?

What are their Pronouns?*

Age of Participant.*

Relationship to Youth Participant*

Do the participants have any physical or intellectual disabilities that might require special accommodations?

Does the youth or family participant have any medical conditions or health concerns that the retreat organizers should be aware of in order to provide appropriate accommodations?

Does the youth or family participant have any food allergy concerns that the retreat organizers should be aware of?

Does the youth or family participant take any regular medication?

Has the youth or family participant ever experienced any challenges (e.g., anxiety, depression, stress, mood disorders, trauma, etc.)?

Does the youth or family participant currently have a mental health support plan, therapist, or counselor?*

Does the youth or family participant have any strategies, coping skills, or tools they use to manage the challenges listed? *

Has the youth or family participant ever experienced any form of trauma (e.g., emotional, physical, or social)? If yes, would you like to share more about how this may impact their experience during an outdoor, nature-based, community-building retreat?*

I understand that after my application is reviewed by the LP team, they will contact me to schedule a follow up call. I understand that space is limited and that filling out this application does not confirm or guarantee a space in the retreat. I understand that this retreat is not a substitute for therapy or medical treatment of any kind. I understand that if participant(s) require psychological and/or medical assistance of any kind, I should obtain these through the appropriate medical channels. I understand that I am responsible for the safety and behavior of the youth that I bring to the camp. I understand the safety guidelines that facilitators/mentors/staff must adhere to. I understand that facilitators/mentors are staff are mandated reporters who must report any suspicion of abuse involving a minor.*

Signature*

Back-To-Land Youth & Family Rolling Application

Additional Family Participant Information

Health Information

Mental Health Considerations