Teen Empowerment Program Application

Thank you for your interest in our Teen Empowerment Program. The following application will give us a little more information about you. After we have received this form, our youth education team will be in touch regarding your application. If we are able to confirm your spot, we will send along a confirmation and registration packet as well as an invoice for your payment.

Student Name*
First Last
Gender*
- Male
- Female
- Non-conforming
Birth Date*
MM slash DD slash YYYY
Grade Level
Email (Student)*
Enter Email Confirm Email
Phone (Student)*
Parent or Guardian Name*
First Last
Address (Parent or Guardian)*
Street Address Address Line 2 City State ZIP Code
Phone (Parent/Guardian)*
Alternate Phone (Parent/Guardian)
Email (Parent or Guardian)*
Enter Email Confirm Email
How did you hear about our Teen Empowerment Program?
Are you a student at Cordova High School?
- Yes
- No
If you are NOT a student at Cordova High, what is the name of your school?
Why do you want to join our Teen Empowerment Program?
What are your areas of interest as they relate to our farm? (growing food, cooking, native plants, greenhouse, flowers, etc.)
Is there any other information we should know about you?
Our Spring Teen Empowerment Program will take place at the farm on the first and third Wednesday of each month from February 2 to May 18. Each session is held at the American River Ranch from 4:00 to 5:30pm.
I understand, and this works with my schedule*
- Yes
- No
This program costs $160 for the full program (which breaks down to $20/session)
Would you like us to send info on financial assistance?*
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.