Mentorship Program - AccountableHero Support Coaching

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Mentorship Program - Pay in Full

Save $100 by paying in full

$1,100.00

Mentorship Program - Two Payments

$600.00

Mentorship Program - Four Payments

$300.00

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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":""}
Age / Grade Level:	{"type":"text","name":"__generic11","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
Parent/Guardian Name & Contact Info:	{"type":"text","name":"__generic12","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
School Attending:	{"type":"text","name":"__generic13","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
City / State:	{"type":"text","name":"__generic14","width":100,"value":"","size":"Normal","validation":"","validationMessage":"Please fill in this item.","placeholder":""}
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"}
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"}

Do you receive public assistance (SNAP, WIC, Medicaid, TANF)? (Check all that apply)

SNAP WIC Medicaid TANF{"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:

Email Phone Virtual Call{"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?

Yes, we are ready to commit and can pay in full. Yes, we are ready but would prefer a payment plan. We would like to be considered for additional financial assistance if available.{"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:
An invoice for school/district accounting Donation receipt for tax purposes (if applicable){"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? Yes No{"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? Yes No{"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 toinfo@tilled-soil.com.

Check below if you will send:

Letter of support from a teacher, counselor, or leader Student quote or short video submission (2 min max){"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

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You will be billed immediately $600.00.

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You will be billed immediately $300.00.

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