Willow Way Permaculture Herb Farm
6481 N 63rd St
Longmont, CO (near Niwot)
80503
303-530-1415
Contact Information:
Name_________________________________________Date____________________
Address_________________________________________________________________
City_________________________________State_________Zip Code_______________
Phone #______________________________Best Time to Call_____________________
Email___________________________________________________________________
Personal Information:
Gender_______________Age__________
Do you exercise regularly?_______If yes, what do you do?________________________
Are you capable of lifting 50 pounds?_______
Do you have a valid driver’s license?_________In what state?_________
Do you have reliable vehicle?_________(not necessary)
Do you have health insurance?_________
Any dietary restrictions?________Please elaborate:______________________________
______________________________________________________________________
Any allergies?_________Please list:__________________________________________
_______________________________________________________________________
Any other important details about yourself (i.e. special needs, religious practices, etc)
_______________________________________________________________________
Please respond to the following questions. Use extra paper if
