The Vermont Farm Immersion Intake Questionnaire

Thank you very much for your interest in our program. Please fill out this application and snail mail it back to me with your $100 deposit.

All of this information will be kept strictly confidential, we totally respect your privacy.

 Date:

 Name:

 Mailing Address:

 Home phone (if applicable):

Cell phone:

 Email address:

 Any children and/or stepchildren? What ages?

 Full time occupation (if applicable):

 What attracted you to this program?

 Which session are you interested in?

 ___Session 1. Sunday, June 23, 2019- Friday, July 19, 2019

___Session 2. Sunday, July 28, 2019- Friday, August 23, 2019

 ___Session 3. Sunday, September 8, 2019- Friday, October 4, 2019

           Your Interests:

Please indicate (with a check) which topics you are most interested in learning about:

 

 

___ Organic agriculture (a deep dive--from soil and seed to harvest and meal creation)

___ Hydroponic agriculture (climate protected, grown in water in a greenhouse)

 ___ Medicinal herbs. Choosing, growing, harvesting, using.

 ___ Animal care (horses and goats)

___ Running a farm stand

 ___ Operating a CSA

___ Creating farm events

(1)  ___ Food Festivals  

(2)  ___ Workshops

(3)  ___ Farm Tours

(4)  ___ School groups coming to the farm

(5)  ___ Pick your own

(6)  ___ Farm Camps for kids

(7)  ___ Farm to table dinners

(8)  ___ Marketing a farm business         

I would like an introduction to:

___ Cheesemaking

___ Cow and goat milking

___ Beer brewing

___ Maple Sugaring

___ Honeybees, pollinators on the farm, and honey

 ___ Growing grapes for wine and eating

 ___ Chocolate making

 ___ Hard cider making, as well as growing apples

 ___ Medicinal herbs. Growing, harvesting, making them into products.

___ Juicing

___ Canning vegetables, making fruit jams

 ___ Making sausage and other meat products. Meat cutting.

___Culinary arts. Food choices, food prep, healthy eating.

         Your Goals:

Please describe your experience, if any, with farming/growing?

 

Are you interested in starting a farm?

 

 

Do you have land for growing currently?

 

Are you interested in buying or leasing land for growing?

 

  

Are you already farming? Please describe:

If you are interested in growing, what types of crops are you most interested in?

 

  

Are you interested in a food related business of your own? If so, what would that look like?

             

YOU

In order to get a sense of who you are, please answer the following questions:

 

 

What do you feel that this experience will do for you? What are you hoping to get out of it?

 

What is your favorite part of your typical day and why?

 

 

 

What is your least favorite part of your typical day and why?

 

 

 

List five adjectives that describe you at your best:

1. 

2. 

3. 

4. 

5. 

 List five adjectives that describe you at your worst:

1. 

2. 

3. 

4. 

5. 

 Is there anything that might get in the way of your participating in this program?

 

What else should we know about you?

 

 

HEALTH HISTORY 

This information is required for participation in the Vermont Farm Immersion Program.

Primary Health Care Physician or Provider:

 

Phone number of Primary Health Care Physician or Provider:

 

Do you have any current, ongoing, or chronic health conditions? No_____ Yes_____  If Yes, please explain:

 

Please check Yes if you’ve been diagnosed or treated for the following. 

Explain “Yes” answers on the space provided below. 

1.    Hospitalized overnight? ___Yes ___No

2.    Heart Condition/murmur? ___Yes ___No

3.    Surgery? ___Yes ___No

4.    Headaches/migraines? ___Yes ___No

5.    Recent contagious disease? ___Yes ___No

6.    Skin Problems? ___Yes ___No

7.    Recent injury? ___Yes ___No

8.    Sleep/sleepwalking problems? ___Yes ___No

9.    Asthma/wheezing ___Yes ___No

10. Seizures? ___Yes ___No

11. ADD/ADHD? ___Yes ___No

12. Digestion/intestinal problems? ___Yes ___No

13. Anxiety/depression? ___Yes ___No

14. Chest pain with activity? ___Yes ___No

15. Immune Disorder? ___Yes ___No

16. Passed out with activity? ___Yes ___No

17. Eating disorder ___Yes ___No

18. Bone/joint disorder ___Yes ___No

19. Allergic to bees? ___Yes ___No

20. Other Allergies? ___Yes ___No Which ones?:

_______________________________________________

Please explain all “YES” answers:

 ALLERGIES:

Any known allergies (food, medicine, bees, and/or other):

 

Please describe the reaction that occurs:

 

How is the allergy treated?

 

Any other health limitations or conditions that we should know about?

 

 

DIET and NUTRITION - We do our best to accommodate a wide range of eating habits but cannot guarantee that all needs can be accommodated. Feel free to bring special foods along that you know you’ll need.

I eat an omnivore diet ___Yes 

I eat a vegetarian diet ___Yes 

I eat a vegan diet ___Yes 

I have the following special food needs: 

 

CONTACTS:

Contact #1:

Email ___________________________________________________________ 

Home Phone____________________________  Cell Phone_____________________________ 

Contact #2: 

Email __________________________________________________________ 

Home Phone____________________________ 

Cell Phone_____________________________ 

 

HEALTH INSURANCE INFORMATION - FILL OUT COMPLETELY  

Insurance Holder_______________________________________________________ 

Relation to Participant________________________________ 

Birth Date of Holder_________________________________________________ 

Subscriber Social Security #_________-________-________ 

Insurance Company

Name_____________________________________________________________  Phone ____________________________ 

Insurance Company Address:

Policy #_______________________________Group

#_________________________________

ID#______________________________________ Is there a co-pay? _________

Program Cost  

This is a 26-day residential program that includes 3 local and organic meals per day

(Sunday, Day 1, includes dinner, 3 meals available for Day 2- Day 25, and Friday, Day 26, includes breakfast), the full program-including all of the field trips, as well as dorm style housing for $3500. (During the weekends we will have a lot of free time with some activities and sight seeing options available.)

 If you are staying elsewhere, we can offer a slight discount of $200. Please let us know that you would like this option.

 A $100 non-refundable deposit is required to save your spot. Though the deposit is nonrefundable, it will be applied to your total fee. If for some reason we have to cancel the program, we will happily refund the deposit.  The total fee needs to be paid by May 1, 2019.

 Will you be staying with us or commuting?

           

Scholarships/grants

 

If you need some financial assistance and you are a Vermont resident that is income qualified, check out the Vermont Non-Degree Program here: https://www.vsac.org/pay/applying-online-financial-aid/vermont-grants

 If you are not a Vermont resident, we are hoping to receive some grant money (the Vermont Farm Immersion Program is a nonprofit registered with the State of Vermont and are awaiting our 501c3 designation from the IRS.) We’ve put out a few grant requests.

 Comments/questions regarding the fee and payments?

 Please mail your application and deposit check to:

Amy Todisco, 264 Quarry Road, Waitsfield, VT 05673

 Email: amy@vtfoodtours.com

 If you need to reach me, don’t hesitate to call my cell: (802) 922-1832.

 We look forward to this amazing adventure with you this summer.

 

-Amy