This will take about 30 minutes to complete.
General Information
| Full Name: | {"type":"text","name":"__generic10","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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| Age / Grade Level: | {"type":"text","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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| Parent/Guardian Name & Contact Info: | {"type":"text","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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| School Attending: | {"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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| City / State: | {"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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| Do you identify as a girl or young woman of color? | Select1. Yes2. No3. Prefer not to say{"type":"select","name":"__generic15","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No\n3. Prefer not to say"}
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| Are you eligible for free/reduced lunch? | Select1. Yes2. No{"type":"select","name":"__generic16","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes\n2. No"}
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Do you receive public assistance (SNAP, WIC, Medicaid, TANF)? (Check all that apply)
{"type":"checkbox","name":"__generic17","width":50,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"SNAP\nWIC\nMedicaid\nTANF"}
Preferred Start Communication Method:
{"type":"checkbox","name":"__generic3","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Email\nPhone\nVirtual Call"}
Financial & Program Readiness
Can you confirm your ability to commit to the discounted program cost of $2,499 for the full 6-month cycle?
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Yes, we are ready to commit and can pay in full.\nYes, we are ready but would prefer a payment plan."}
Would you need:
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"An invoice for school/district accounting\nDonation receipt for tax purposes (if applicable)"}
Program Alignment
Why are you interested in participating in the Tilled Soil mentorship program? (Brief paragraph)
{"type":"textarea","name":"__generic22","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
What are your primary goals or outcomes for your girls/students/self from this experience?
{"type":"textarea","name":"__generic23","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
How does this program align with your school’s or personal values regarding identity, leadership, and healing?
{"type":"textarea","name":"__generic24","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Are there any support systems in place to ensure students attend and engage in sessions (ex: counselors, facilitators, parents)?
{"type":"textarea","name":"__generic25","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please fill in this item.","height":80,"placeholder":""}
Data + Impact Tracking Consent
Are you willing to participate in anonymous pre- and post-program surveys for impact tracking?
{"type":"radio","name":"__generic4","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
Do you consent to allow student stories or testimonials (with permission) to be used for future reporting?
Select1. Yes, with approval.2. No, we prefer not to share.{"type":"select","name":"__generic27","width":40,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Select\n1. Yes, with approval.\n2. No, we prefer not to share."}
Would you be open to participating in a brief follow-up interview at the end of the cohort?
{"type":"radio","name":"__generic18","width":30,"value":"","size":"Normal","validation":"","validationMessage":"Please make a selection for this item.","options":"Yes\nNo"}
OPTIONAL UPLOADS
If you would like to share any of the following, please send them to
Check below if you will send:
{"type":"checkbox","name":"__generic","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please check at least one item.","options":"Letter of support from a teacher, counselor, or leader\nStudent quote or short video submission (2 min max)"}
Final Confirmation
By signing below, you confirm your interest in participating in the Tilled Soil Beta Cohort and agree to the terms and conditions of your chosen payment terms. All payments are secure and will be processed via Stripe on the Coach Accountable interface.
Signature:
{"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your signature.","height":150}
2/3/26
