Chicken Sanctuary - Survival Gardening for the Urban Prepper

E-mail Address: *

My interest *

Rent Bedroom at Center
Rent a RV or 5th Wheel at Center
Have my own RV
Have my own 5th Wheel
Have my ownTravel Trailer
Other

If you marked other above, please explain

When will you be available to join us *

Why that particular date? *

If you are furnishing your own Rig does it have

Working Shower?
Working Heating?
Working Toilet?

# of people over 16 of age, the second person is required to attend all Workshops in addition to the 21 Barter-Hours *

Prefix *

Mr
Miss
Mrs
Ms
Dr

Primary Person *

What states have you lived during the last 10 years *

Birth Date * / /

Do you have any physical limitations with *

Back
Legs
Arms
Emotional\Mental Problem
Have no Limitations
Other

If you marked Other please explain

What are your skills *

Construction
Web Design
Carpenter
Writing Articles & Blog
Plumbing
Electrical
Solar
Landscaping
EMT
Medical
Animal Care
Gardening

Have you ever been convicted of a felony? *

Yes
No

Do you give your permission for a background ckeck? *

Yes
No

Second Person Prefix

Mr.
Miss
Mrs
MS
Dr

Second Person Name

What states have you lived during the last 10 years

Birth Date / /

Do you have any physical limitations with

Back
Legs
Arms
Emotional\Mental Problems
Have no Physical Limitations
Other

If you marked Other please explain

Have you ever been convicted of a felony?

Yes
No

Do you give your permission for a background ckeck?

Yes
No

What are your skills

Construction
Carpenter
Web Design
Plumbing
Writing Article & Blog
Heating
Electrical
Animal Care
Solar
Medical
Gardening
Landscaping

# of Children

Name of Oldest

Oldest Child Date of Birth____________________________________________ / /

Do you have a Pet? If so, what is it name and describe *

Relationships *

Married
Single
Partner
Divorced

How long have you been at this status *

Less than one year
Between 1 and 5 years
Between 5 and 20+ years
All my life

Type of vehicle will you be driving? *

Truck
4 WD Truck
Car
No Vehicle
Other

What is causing you to apply for this lifestyle *

Would you like to learn more about *

Gardening
Chickens
Ducks
Goats
Cow
Horse
Other

The Temperature on the Oregon is nearly always between 40 – 70 degrees and it is cloudy and rains a lot. Why do you want to want to leave where you are for this lifestyle? *

Do you have source of money for *

Food
Fuel
Propane
Medical Care
Personal Items
Other

What is the source of your money? *

Social Security
Retirement Income
Unemployment
Food Stamp
Have to get a local job
SSI
Saving
Other

Do you

Need Internet
Owe a Gun
Want to Fish
Use Illegal Substances

Name of Emergency Contact that will not be living with you *

Relationship *

Phone Number *

Employer or some who can comment on your working habits *

Position *

Their Phone Number *

Your Current Phone Number *

Your Current Address *

Your Current City *

Your Current State *

Your Current Zip Code *

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