Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Location of Design Property

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Desired level of food self-reliance *

Check One Box (provided examples are approximations to give you an idea of potential options)

None

Minimal (ex. a few herbs and/or Veggies)

Minimal+ (ex. Several months of supplemental herbs/veggies, limited fruit)

Moderate (ex. 2 handfuls of fruit May- October, Veggies/greens year round, no animals)

Moderate+ (ex. excess/preservable fruit May-October, Veggies/greens year round, Small livestock (chickens/quail/rabbits))

Maximum (nearly all fruit, veggies, and protein. Supplemental grain and dairy is still purchased)

Maximum+ (All fruit, veggies, dairy and protein. Supplemental grain is purchased

Fully self-reliant (no external inputs required)

Other…

What is the current level of food skills/experience? *

Check One Box (provided examples are approximations to give you an idea of potential options)

None

Minimal (ex. grown and maintained a small seasonal garden)

Minimal+ (ex. grown and maintained a large seasonal garden)

Moderate (ex. grown large fruit and veggie garden year round)

Moderate+ (ex. All the above, plus basic food preservation and small livestock)

Maximum (ex. All the above, plus large livestock (not dairy))

Maximum+ (ex. All the above plus dairy animals)

Fully self-reliant (no external inputs required)

Other...

What is the desired level of food skills/experience? *

Check One Box (provided examples are approximations to give you an idea of potential options)

None

Minimal (ex. grow and maintained a small seasonal garden)

Minimal+ (ex. grow and maintained a large seasonal garden)

Moderate (ex. grow large fruit and veggie garden year round)

Moderate+ (ex. All the above, plus basic food preservation and small livestock)

Maximum (ex. All the above, plus large livestock (not dairy))

Maximum+ (ex. All the above plus dairy animals)

Fully self-reliant (no external inputs required)

Other...