Exit this survey HABESHA Works 2015 Application 1. Question Title * 1. Thank you for interest in the 2015 HABESHA Works Program. HABESHA Works begins on April 1, 2015. Please complete the following personal information. Name: Address: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: Email Address: Phone Number: Question Title * 2. What is your age? 18-25 26-30 31-35 36-40 41-45 46-50 50 & above Question Title * 3. What is your ethnicity? Black or African Descent White or European Descent Hispanic or Latino Asian Descent Multiracial Other Question Title * 4. What interests you about the HABESHA WORKS Training Program? (click all that apply) Growing a home garden Growing a community garden Business opportunities in urban agriculture Garden design and management Health and Nutrition Personal development Other (please specify) Question Title * 5. Describe any previous experiences that you may have with gardening, landscaping, or farming (if any). Question Title * 6. Are you interested in pursuing career opportunities in urban agriculture? Yes No Question Title * 7. Do you have any health conditions that will prohibit you from working in rigorous physical outdoor activity under a variety of weather conditions? No Yes If Yes (please specify) Question Title * 8. With your current mode of transportation, are you able to participate fully in course activites as well as complete independent assignments/projects outside of scheduled class time (6-8 hours/week)? Yes No Question Title * 9. How did you hear about HABESHA Works? Radio Internet Search Referral from previous HABESHA Works participant Email from HABESHA Newspaper Email/referral from another organization Other (please specify) Question Title * 10. IF YOU ARE INTERESTED IN APPLYING FOR A FULL OR PARTIAL SCHOLARSHIP, PLEASE ANSWER THE FOLLOWING QUESTIONS.What is your annual household income? Less than $20,000 $20,000-$24,999 $25,000-29,999 $30,000-34,999 $35,000-$39,999 $40,000-$44,999 $45,000 or more Question Title * 11. Number of Related Persons in Household? 1 2 3 4 5+ Adults Adults 1 Adults 2 Adults 3 Adults 4 Adults 5+ Children Children 1 Children 2 Children 3 Children 4 Children 5+ Question Title * 12. If given a scholarship, are you willing to complete 30 hours of volunteer time over the 14-week course? YES NO Question Title * 13. Your participation in a orientation session is required for your consideration. Please indicate which session you will be able to attend. Sessions will be held at Omenala Griot Museum located at 377 Dargan Pl. Atlanta, GA 30310 from 6-8PM. Wednesday March 4, 2015 Wednesday March 18, 2015 Done
