Registration for Fayetteville Earth Day Tree Planting

Funding provided by USDA NIFA Renewable Resources Extension Act and 1890 Capacity Building Programs

Please complete this form to register for the Fayetteville Earth Day Tree Planting event which will take place on Tuesday, April 24, at the New Roots Community Farm. This event is in partnership with the WV Tree Minders certification program.

Please dress appropriately for the weather and bring your own gardening or work gloves. Tools will be provided. For more information, please contact Extension Agent Liz Moss at elizabeth.moss@wvstateu.edu or (304) 661-6016

or Dina Hornbaker at dina@newrootscommunityfarm.com.

Thank you for completing this form. The information collected is used as part of our evaluation process for funding purposes and to assist us to provide you with quality educational programs. Information that is collected is held in the strictest confidence and is not disseminated. WVSU Research and Development Corp. is an Equal Opportunity/Affirmative Action Employer and does not discriminate against any person because of race, sex, age, color, religion, national origin or disabilities.

Question Title

* 1. What is your name?

First

Middle

Last

Suffix

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* 2. What is your gender?

Male

Female

Nonbinary (please specify)

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* 3. In what year were you born?

Year (YYYY)

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* 4. Would you like more information about the free WV Tree Minders tree care certification program? If yes, please provide your email in question 5.

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* 5. What is your contact information?
Please at least provide a working email so you can receive updates about any changes to training dates or times, due to weather.

Company / Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 6. Which race/ethnicity best describes you? (Please choose only one.)

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

White / Caucasian

More than one race

Other (please specify)

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* 7. Are you of Hispanic or Latinx origin or descent?

Yes, Hispanic or Latinx

No, not Hispanic or Latinx

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* 8. What is your military status?

Veteran

Active

Reserves

Dependent Family Member

No Military Service

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* 9. Have you operated a farm or ranch for more than 10 consecutive years?

Yes

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* 10. Where do you currently reside?

Farm

Rural (under 10,000 residents)

Town (10,000 to 50,000 residents)

City (over 50,000 residents)

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* 11. What is your approximate household income bracket?

Less than $9,999

$10,000-$19,999

$20,000-$29,999

$30,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$149,999

$150,000 and up

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* 12. Was your Total Household Income for each of the last two years less han $25,100?

Yes

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* 13. Do you have a disability?

Yes

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* 14. We strive to host accessible events that enable individuals of all abilities to engage fully. Do you need any accommodations in order to participate (such as captioning, large print documents, translation services, or others)?

Question Title

* 1. What is your name?

Question Title

* 2. What is your gender?

Question Title

* 3. In what year were you born?

Question Title

* 4. Would you like more information about the free WV Tree Minders tree care certification program? If yes, please provide your email in question 5.

Question Title

* 5. What is your contact information? Please at least provide a working email so you can receive updates about any changes to training dates or times, due to weather.

Question Title

* 6. Which race/ethnicity best describes you? (Please choose only one.)

Question Title

* 7. Are you of Hispanic or Latinx origin or descent?

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* 8. What is your military status?

Question Title

* 9. Have you operated a farm or ranch for more than 10 consecutive years?

Question Title

* 10. Where do you currently reside?

Question Title

* 11. What is your approximate household income bracket?

Question Title

* 12. Was your Total Household Income for each of the last two years less han $25,100?

Question Title

* 13. Do you have a disability?

Question Title

* 14. We strive to host accessible events that enable individuals of all abilities to engage fully. Do you need any accommodations in order to participate (such as captioning, large print documents, translation services, or others)?

* 5. What is your contact information?
Please at least provide a working email so you can receive updates about any changes to training dates or times, due to weather.