Tots Programs- Seeds of Success Application Parent Name * First Name Last Name Student Name * First Name Last Name Student Age * Email * Phone (###) ### #### Address Which season would you like to apply for? * Spring 2025 - Wonder gardening only Summer 2025 Fall 2025 Full Year 2025 Which tot program are you applying for? * Mom & Me Garden Club (Spring full) - Fridays 10-11:30am Wonder Gardening - Fridays 4-5:30pm Garden with Me (Spring full) - Saturdays 10-11:30am Today's Date MM DD YYYY Were you referred to us by WellMama? * Yes No I don't know Please select your ethnicity The following information is for our own internal reporting purposes and does not affect the status of your program participation. We do not share any personal information publicly Hispanic Non- Hispanic I do not wish to disclose Please select your race The following information is for our own internal reporting purposes and does not affect the status of your program participation. We do not share any personal information publicly White Asian Black or African American Native Hawaiian or Other Pacific Islander American Indian or Alaska Native I do not wish to disclose bi racial/ multi racial How would you describe where you live? Urban Area Rural Area What school district does your student attend * We understand that financial circumstances can vary. If you or your household are facing challenges that make it difficult to pay the full program fee, please let us know. You may be eligible for a discount. If you’re comfortable, please feel free to share any details about your situation that may help us better understand your needs. * Are you currently receiving any of the following public benefits? SNAP, WIC, or Food Stamps Medicare/ Oregon Health Plan (OHP) Temporary Aid for Needy Families (TANF) Financial Assistance- SSI Social Security- SSDI Public Housing None of the Above Other Electronic Signature: I have given the information above and to the best of my knowledge it is true and accurate. I agree to allow Parker Learning Gardens to contact any/all the above mentioned agencies to verify my participation. I have read and agree with the statement above Thank you! You will receive an email with in 7 days of submission. If you do not, please email Sasha@parkerlearninggardens.org
