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 $3,000 for the full 9-month cycle?
{"type":"checkbox","name":"__generic19","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.\nWe would like to be considered for additional financial assistance if available."}
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
Check below if you will send:
{"type":"checkbox","name":"__generic2","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 Mentorship Program.
Signature:
{"type":"signature","name":"__signature","width":100,"value":"","size":"Normal","validation":"NE","validationMessage":"Please enter your signature.","height":150}
2/18/26