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Mother Earth Ambassador Program - Intake Form
Thank you for your interest in the Mother Earth Ambassador Program. Please complete this short intake form and we will review it and get back to you to schedule a follow up interview as soon as possible.
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Email
*
Your email
Child's Name
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Your answer
Child's Birth Date
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MM
/
DD
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YYYY
Parent's Name
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Your answer
Parent's Phone Number
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Your answer
Please share a little about yourself and your child, and why you would like her to attend the Mother Earth Ambassador program?
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Your answer
Describe your child's experience and comfort level being outdoors.
The kids will be outside for full days in all types of weather. Has your child attended outdoor programs, camps or courses before?
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Your answer
Is your child attentive in following group plans, and do they enjoy being a part of a group? Do they have a tendency to run off at any time?
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Your answer
Please describe your child's character in social settings. What behavioural information can you share? Has your child been diagnosed with ADD, ADHD, Autism, Anxiety, etc? All information is entirely confidential.
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Your answer
Please confirm your understanding of the following:
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I understand that the information contained in this form is considered private and confidential and will be treated accordingly, in adherence to FWOCC and Wise Earth Forest School policies.
I understand that as a condition of enrolment, a signed waiver will be required before attending the first session.
I understand that I am applying to place my child in a nature-based learning program and that they will be supported as they engage in safe "risky" play such as steam wading, tree-climbing, etc.
Required
We have a limited number of full bursaries available for families in financial need. Are you interested in applying for one of these bursaries?
Yes
No
Maybe
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Is there any other information that you would like to share with us?
Your answer
How did you find out about the program?
*
Your answer
A copy of your responses will be emailed to the address you provided.
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