To apply for the Summer or Fall Ecovillage and Permaculture Certificate Program, please fill out the questionnaire below. There are no specific pre-requisites of knowledge needed for the course, so please do not be concerned if you have little background in any or all subject areas. Your answers help us to understand what the average level and diversity of knowledge in the group will be. The information in the questionnaires helps us respond to the backgrounds and interests of the participants as best we can within the framework of the program and the requirements for the certificates. Concise responses to the questions are appreciated.
To mail, send the completed questionnaire to the Lost Valley address at the bottom of this page. To print this page, scroll to the bottom of this webpage and press the "Printer Friendly Version" button.
To email, copy this questionnaire out of this webpage into a word processor, add your answers and email them to epcp <at> lostvalley <dot> org. [1]
In order for us to reserve a space for you in these programs, you will also need to provide a security deposit. Instructions for the security deposit are at the bottom of this questionnaire.
Please mark which program you are applying for:
__ 8 week summer course __ 4 week fall course
Name :
Address: City: State: Zip:
E-mail address:
Day phone: Evening phone:
Date of birth:
How did you hear about the course?
On a scale of 1-10, with 1 being not at all interested, 5 being average interest, and 10 being very interested, please indicate your interest level in the following subjects (if you don’t know you can leave it blank):
Land and Garden:
Permaculture design principles and process__ plant identification___organic gardening___, landscape design and maintenance___, developing hands-on physical skills___food self-sufficiency__, crafts___, urban permaculture___, other_______________________,
Built environment:
Ecobuilding___, energy efficiency and renewable energy___, water catchment, greywater and composting toilets___, eco-village site design___other_______________________
Human Community:
Decision making systems___, personal growth___, interpersonal communication___, community economics___, ecovillage legal and zoning issues___, someday living in an intentional community___, survivalism/primitivism ___bringing these subjects to “the mainstream”___, integral philosophy/spiral dynamics___, other_______________________
Occupation:
If you are currently a student, please indicate which school/college, year and department. Are you planning to receive college credit for this course? Through which institution?
What is your education level and experience in ecology?
What is your education level and/or experience related to building (green or conventional) or appropriate technology?
What is your education level and/or experience in subjects related to living in community, group facilitation, decision making processes, project planning, or business administration?
Any other areas of expertise or knowledge:
Do you have specific goals for what you plan to do with what you learn here after the course?
Do you live in an urban, suburban or rural setting?
Community involvement and affiliations:
Are you okay with living in a rustic, rural intentional community for the period of the course?
Are you comfortable participating in hands-on projects?
Are you comfortable being in an environment where you will have the opportunity to look at and take responsibility for your own behavior patterns?
What challenges do you expect might come up for you?
Please list any health problems, special needs, addictions, food allergies or special food needs or other comments:
Payment
I have read the below and I am submitting a deposit which will go towards my course tuition, by (please check one):
a. __a check for $_____ is included in the envelope with this form.
b.__I will call in with a credit card number.
c. I will send in a check at the following time _____.
In order for us to reserve a space for you in the program, you will need to submit a $400 security deposit which will go towards your course tuition. The security deposit is not processed until you are accepted into the program. If you are not accepted into the program the deposit is not processed-- the check is torn up or credit card number not processed and purged from our records. If you are accepted and then decide not to attend the program, $75 of your deposit is non-refundable from the time you are accepted and the remainder of the deposit is non-refundable after May 16th for the summer course/Sept 5th for the fall course. The final payment is due by May 30th for the summer course/Sept 15th for the fall course.
You can submit the deposit as soon as you submit the registration form, or after we confirm your acceptance, whichever you prefer. All payments by check/money order should be sent to:
Lost Valley Educational Center
EPCP Registration
P.O. Box 55
Dexter, OR 97431
Or to use a credit card, please call EPCP Registration: (541) 937-3351 x 106
Thank you for your application.
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