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High Ridge Harmony Farm: Registration form
The information in this form is confidential and is only used by the High Ridge Harmony Farm Program team. The information is used to help us select the best environment and healing/wellness activities.
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* Indicates required question
Name of the person who will participate in the program (participant)
*
Your answer
Participant contact information (email and/or phone).
If participant is a minor you do not need to share this information.
Your answer
Parent/guardian/supporter name
*
Your answer
Parent/guardian/supporter contact information (email, phone)
*
Your answer
The referral is from
Adjustment Counselor
Doctor
Friend
Guidance Counselor
Social worker
Therapist
Other:
Would you like to take a Tour? We offer tours on Saturday mornings - please select your preference
Tour time 9:45am-10:45am
Saturday, May 6
Saturday, May 20
Saturday, June 3
Saturday, June 10
Other:
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