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Envision Herbal First Aid Clinic Application
All prospective students are asked to fill out the application, so we can get to know a bit about you, your background, goals and intentions.
Please send any questions to
study@ecologyacademy.com
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Name
*
Your answer
Email
*
Your answer
Phone Number
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Your answer
Other ways to contact you (WhatsApp, FB, etc.)
Your answer
Gender Identity
Female
Male
Prefer not to say
Other:
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Age
Your answer
Native Language
Your answer
Other Languages Spoken and Proficiency
Your answer
Home Town
Your answer
Current Location
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Stamina
Slow to rise, slow and long memory and energy, grounded
Active and a quick retainer, quick dissipator, fiery
Dissipating energy, quick to understand, quick to lose, airy
Other:
Clear selection
What about this course specifically piques your interest?
Your answer
In what capacity have you been studying/practicing Herbalism? At home, online, with a mentor/teacher, working, conferences and short workshops, university etc… If you have studied formally with a teacher, who/when/where.
Your answer
What is your level of experience as a health care practitioner?
Beginner
Intermediate
Advanced
Master
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What do you consider your top skill and/or specialty?
Your answer
Do you have any medical training? EMT, Clinical Herbalist, First Air, WFR, Nursing, Street Medic, Midwife, Mental Health, etc.
Your answer
Do you have any other therapeutic trainings? Massage/body work, acupuncture, homeopathy, yoga, counselling, etc.
Your answer
Do you have any trainings/studies in wildlife, biology, botany, mycology, marine sciences or other ecological studies?
Your answer
What is your favorite plant right now and why?
Your answer
Have you spent time outdoors, if yes, where is the most beautiful place you have seen?
Your answer
Do you attend or have worked at festivals or other mass gatherings, if yes, in what capacity, on what teams, and for how long?
Your answer
In regards to social and ecological resilience, what makes you feel the most empowered and what makes you feel the most disempowered?
Your answer
Have you lived in community before? If yes, in what capacity, where and for how long? Summer camp also counts as community.
Your answer
What is your greatest strength?
Your answer
What is your greatest limitation?
Your answer
Describe the methods you employ to deal with stressful situations and conflict
Your answer
How will you shine in the clinic training?
Your answer
What else can you bring to the table as an offering? (skills, gear, supplies, equipment, allies, food, herbs, etc)
Your answer
Dietary Preferences/Allergies (Gluten-free, no lactose, vegan, vegetarian, etc.)
Your answer
Any physical or mental health conditions we should be aware of?
Your answer
Emergency Contact
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How did you hear about the program/Who referred you?
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