Poetry in Nature: Transforming Parts & Pain
November 9, 2024
10:00 AM - 5:00 PM
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TRANSLATE THIS FORM: Español, Português, Tiếng Việt, Tagalog, Kreyòl ayisyen
FOR WHOM?
I WILL PARTICIPATE
YOUR (PARENT/GUARDIAN) NAME:
YOUR (PARENT/GUARDIAN) CONTACT INFORMATION:
NAME:
(not parent)
CONTACT INFORMATION:
(OPTIONAL)
BIRTHDATE:
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GENDER:
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Male
Female
Non-Binary
PRONOUNS:
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He/Him/His
She/Her/Hers
They/Them/Theirs
LANGUAGE:
(only if not English)
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HOUSEHOLD/FAMILY DETAILS:
PARTICIPANT MAILING ADDRESS:
* ONLY IF OUTSIDE OF USA
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PERSONAL INTRODUCTION
TELL US ABOUT YOURSELF:
TELL US ABOUT YOUR CHILD:
What specifically interests you in this program?
What other interests / hobbies / activities do you enjoy?
What specifically interests your child in this program?
What other interests / hobbies / activities do they currently enjoy?
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HOW DID YOU FIND US?
Please help us understand
which of our marketing efforts are most effective
by checking the factor or factors
that most influenced your decision to register!
WORD-OF-MOUTH:
A friend or family member told me about it
WEB:
I searched for something on the internet and found your website
SOCIAL-MEDIA:
I saw something on social media: Instagram, Facebook, etc.
EMAIL:
I received a marketing email or e-newsletter from you
BROCHURE:
I received or read a printed brochure or program catalog
POSTER:
I saw a poster on a bulletin board
PRINT:
I saw a printed advertisement or article in a newspaper or magazine
ADVISOR:
A school counselor, advisor, or paid consultant recommended it to me
ENCOUNTER:
I randomly encountered your staff or students while we were out in the world
EVENT:
I found your table or display at a school, fair, or other public event
MYSTERY:
A mysterious force has led me here; I cannot explain it
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YOU MUST CHOOSE ONE OF THESE OPTIONS:
$225.00
TUITION A-SUPPORTING-TIER-POETRY
This tuition tier supports those paying on the lower end of the scale and helps Journeys develop future programs
$190.00
TUITION B-STAFFING-TIER-POETRY
This tuition tier covers our full costs with administrative overhead
$160.00
TUITION C-SUSTAINING-TIER-POETRY
This tuition tier covers our direct costs of running the program.
$125.00
TUITION D-SUPPORTED-TIER-POETRY
This tuition tier falls short of covering our direct expenses
$40.00
TUITION Z-FINANCIAL-AID-COMMUNITY-PROGRAMS
We require that everyone applying for financial aid for Community Programs pays at least $40 to secure a spot in the program. After you register, you will receive a Financial Circumstances Questionnaire and your final financial aid determination will be determined based on annual income, family size and answers on your Financial Circumstances Questionnaire
SHOPPING CART
ADJUST QUANTITIES:
ITEM
QUANTITY
SUBTOTAL
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NEWSLETTER OPT IN
Please opt in below to be added to our newsletter email list!
Would you like to be added to our newsletter to receive occasional emails about our programs and community updates?
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ALMOST DONE, KEEP GOING!
PLEASE COMPLETE THIS VALIDATION:
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