Name
*
First Name
Last Name
Preferred Name (if different)
Email
*
Phone
*
(###)
###
####
Pronouns
*
Birth date
*
MM
DD
YYYY
Parent/Guardian Names
Parent/Guardian e-mail(s)
Parent/Guardian phone
(###)
###
####
Emergency Contact Name
*
Emergency Contact Number
*
Country
(###)
###
####
Relationship to emergency contact:
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Expiry
MM
DD
YYYY
Self-Identification
*
Nation(s)/Communit(ies)
*
Please tell us about the communities you are connected to. This can include one or more reserves, urban or rural Indigenous communities, non-Indigenous identities, or "still learning".
Why are you interested in a land based learning mentorship?
*
Can you tell us about some areas of land based learning that you are already involved in, or how you are working to build knowledge in these areas?
*
What is your availability like?
*
What are some areas of land based learning you'd like to explore?
*
Is there anything else you want to learn?
Is there anything you do not want to be apart of?
Do you have any health or accessibility needs you would like us to know?
Including dietary restrictions
We try to capture some of our special moments and milestones through photos and videos, and with your permission, may share them on our social media accounts. If you are over 18, do you consent to your photo being taken and shared?
N/A- Under 18
Yes
No
Maybe, ask first please
Is there anything else we should know?
