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Grounding Roots Virtual Learning
Student Interest Survey
Parent or Guardian's Name
*
First Name
Last Name
Student's Name
*
First Name
Last Name
Student's Age
*
Student's Grade
*
Parent's E-mail
*
Student's E-mail
example@example.com
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Which Tribe is your student affiliated with?
*
Is your student familiar with their cultural practices?
*
Yes, Very involved
Yes, a little
Not really
No, but wants to learn
If so, what do they enjoy participating in?
Does your student have an IEP or 504 plan?
*
Yes
No
If so, what types of accommodations are helpful?
Does your student have allergies?
*
Yes
No
If so, what is your student allergic to?
What is your student most interested in Learning? Please pick your top five
*
Beading
Weaving
Indigenizing Apparel
Sewing
Drumming
Language
History
Nutrition and Wellness
Drawing and Painting
Wood Carving
Instrument Making
Decolonized Systems
Moccasins
Bags
Leather Work
Ribbon Work
Feather Work
Necklaces and other Jewelry Making
Accessories
Other
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 More
Yes
No
Maybe
Other
Is your student interested in becoming a member of the Unci Maka/Na’ah Ili’i/ Mother Earth Rescue Team?
*
Tell Me More
Yes
No
Maybe
Other
Is your student interested in Indigenous Based Educational Mentorship?
*
Tell Me More
Yes
No
Maybe
Other
Which Virtual Platform do you like best?
*
Seesaw
Canvas
Google Classroom
Zoom
Other
Which DAYS are best for your student to participate in our classes or talking circles?
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
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?
Submit
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