Hope Grows Community Farm Program
Date___________
Participant Information Sheet B
General Information
Program ___________________
Participant’s Name:________________________________________________________
DOB:_____________
Age:________
Gender: M
F
Parent/Guardian (1) Name:_____________________________________________________
Mailing
Address:_______________________________________________________________________
Home Phone:________________
Parent/Guardian (2)
Cell Phone:__________________
email:_________________
Name:_____________________________________________________
Mailing
Address:_______________________________________________________________________
Home Phone:________________
Cell Phone:__________________
email:_________________
How did you hear about the
program?_________________________________________________________
***In the following section, please circle either I DO or I DO NOT, but not
both.
Photo Release:
I DO/DO NOT (please circle) consent to and authorize the use and reproduction by Hope Grows
Community Farm Program of any and all photographs and any other audio/visual materials taken of me
for promotional material, educational activities, exhibitions, program related social media sites, or for
any other use for the benefit of the program.
Signature: ________________________________________
Participant, Parent, or Legal Guardian
Date: ________________
Participant’s Name _____________________________
Date ______________
We would like the participant to fill out this section in their own words. Parents,
guardians, or service providers can scribe for the participant or read and explain
the questions to them as needed.
Why do you want to come to Hope Grows?
What short term or long term goals do you hope to accomplish at Hope Grows?
Name two or three of your personal strengths.
Name one or two areas where you think you need personal improvement.
Tell us about your hobbies and interests.