Institute for Place-Based Education Registration Form

Institute for Place-Based Education

In partnership with Vermont State University’s Center for Schools, Willowell Foundation is pleased to offer courses in placed-based learning. We are now enrolling for our two Spring Semester 2026 offerings, The Writing of Place and The Literature of Place. You may register for one or both course offerings below. Please note: If you are seeking credit for your course participation, you will also need to complete the VTSU registration (which will be emailed to you after completing this form).
General Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Would you like to stay informed of future Willowell programming via our newsletter and an occasional email?

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Are you a Vermont resident?

YesNo
Academic and Professional Information
I am registering for a:

Graduate 3 credit course (as a non-matriculating student)Undergraduate 3 credit course (as a non-matriculating student, Literature of Place only)Other (you are not seeking to earn credit)
Please select which is applicable. You may choose one or more of the options below.

Current Graduate StudentCurrent Undergraduate StudentEducator Seeking Professional DevelopmentOther
If you selected other, please explain your current academic and/or professional standing.
If you are currently enrolled in a program of study, please indicate the name of the school and program title below.
If you are an educator, please tell us your position and the name of the school or program of which you are employed.
Any considerations you wish us to know? This is a place to explain any physical or academic considerations you may need accommodations for.
Liability Waiver

In consideration of permission to participate in Willowell Foundation's events and activities:

A. I fully understand and acknowledge that outdoor activities have inherent risks, dangers, and hazards; such hazards may exist during my (our) participation.

B. Participants in such actitivities may result in injury or illness and by participating in these activities, I hereby assume all risks and dangers and all responsibilities for any losses and/or damages, whether caused in whole or in part by the negligence of the instructors, staff/officers or contracted employees of Willowell Foundation, the negligence of the participants, the negligence of others, accidents, the forces of nature, or other causes.

C. I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive discharge, hold harmless, defend, and indemnify Willowell Foundation instructors, staff/officers or contracted employees from any and all claims, actions, or losses for bodily injury, property damage, wrongful death, or otherwise which may arise out of my participation in Willowell Foundation activities.

I have read the above waiver, and by signing it I agree. It is my intent to exempt and relieve Willowell Foundation from liability for personal injury, property damage, or wrongful death caused by negligence or any other cause.
Date

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
Photo Waiver

We may take pictures/videos of you throughout the course to document our offerings. By signing below, I authorize The Willowell Foundation to publish the photographs or video taken for use in printed publications, e-newsletters, videos, and on authorized websites (Willowell.org, Vermont State University's website, Willowell Facebook and Instagram). I acknowledge that since participation in media produced by the Willowell Foundation is voluntary, we will receive no financial compensation. I further agree that participation in any media produced by the Willowell Foundation indicates no rights of ownership whatsoever. I release the Willowell Foundation and their employees/contractors from liability for any claims by me or any third party in connection with their participation. By signing your name/date below, You authorize the Willowell Foundation (“Willowell”), to publish the photographs or video taken of you (first names used only, if any), for use in printed publications, e-newsletters, videos, and on authorized websites.

You do hereby release Willowell and its officers, directors, members, employees/contractors, and associated personnel from any and all manner of liability for any and all manner of claims by You, or any third party in connection with their participation.

If you do NOT wish to sign this waiver, please leave the signature field blank and indicate that you do not consent in the comment section below.

I agree to the above terms.
Date

MonthDayYear
Date
Signature

Powered by Jotform SignClear
Subject to Change Waiver

The Willowell Foundation, in partnership with VTSU, reserve the right to adjust course offerings on the basis of operations, scheduling, logistics and procedures as educational and financial considerations unforeseeably arise. Please sign below to confirm your acknowlegment.
Date

MonthDayYear
Date
Signature*

Powered by Jotform SignClear

Selected courses are refundable for 30 day after purchase, less the processing fee. Please select and pay for your courses below.*

The Writing of Place Course (graduate level only)

$2,200.00 Quantity

The Literature of Place Course

$2,200.00 Quantity

Enter coupon

Total

$0.00

loading smart payment buttons...

Should be Empty:

Institute for Place-Based Education

General Information

Academic and Professional Information