Name *

First Name

Last Name

Are you, or were you a police officer? *

YES

NO

Would you be comfortable participating with someone that is of a higher rank than you if they were from a different working area? *

YES

NO

Please select which best describes your current employment as an officer: *

Active Duty

On Leave

Resigned

Retired

Other

What is the best number to reach you? *

We communicate primarily through email, however we appreciate having a secondary way to reach you.

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Do you commit to participating for the entire 7-week process of this program? *

Week 1: 4-day Intensive at the farm | Week 2-6: 2-hours online per week | Week 7: 1/2 day at the farm (dates are listed on the previous page)

YES

NO

For safety reasons, this program will require you to attend completely sober. Are you able and willing to commit to this? *

YES

NO

Would you be willing to participate in a video to support the fundraising required to make this program available to other first responders? *

You will not be forced to do this if you participate, and this is only something being asked of participants in the pilot program.

YES

NO

What is your emergency contact's phone number? *

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