Please answer all questions and return this form at least one week before you arrive--along with a non-refundable deposit of $100 per adult and $50 per child. Use one application for each adult. Send to CEW, Lost Valley Educational Center, 81868 Lost Valley Lane, Dexter, OR 97431. If you have questions, contact our Membership Coordinator, Dianne Brause, at diannebr@lostvalley.org [1] or (541) 937-3351 x122.
Name: ___________________________________ Age: _____ Date: ___________
Address: _______________________________________________________________
Phone: (____)____________(____)___________ Best time(s) to call: _____________________
E-mail: ___________________________ Dates you wish to be here: _____________
Travel Arrangements:Car___Train___Bus___Plane____Arriving_____Departing_____
*There may be an extra charge for pick-ups but they can be arranged from Eugene.
Can you offer a ride-share?From?____________
Children coming with you:
Name: _______________________M__F__Age: ______
Name: _______________________M__F__Age: ______
Name: _______________________M__F__Age: ______
Emergency contact: Name_____________________
Relationship_____________ Phone: (____)________________
Email___________________
Please use extra space if you need to answer the following questions:
1. How did you learn about Lost Valley Educational Center?
2. Have you ever lived in community before? Please describe.
3. What are your thoughts and feelings about living in community?
4. What experience, if any, have you had with consensus as a decision-making process?
5. What are some things you want to learn during Community Experience Week?
6. What are some of your interests and passions?
7. Are you coming with the thought that you may want to join Lost Valley in the near future? Or just to learn more about community living in general?
8. If you have any mental, emotional or physical health concerns or difficulties that we should know about, please describe:
9. We serve vegetarian food.
Do you prefer wheat-free dishes? _______
Do you prefer dairy-free options? _______
Do you prefer raw options? _______
Other food needs? Please describe below:
10. Is there anything else that you think we should know, or that you want us to know, about you and/or your children?