Growing Places Registration Form

Growing Places Registration—Fall 2005

Growing Places is designed for individuals:
• who are considering starting an agriculture or natural resource based business, but
• who aren’t sure where to start.

Growing Places is designed to help participants:
        • develop a comprehensive goal statement which will help in the business planning process
        • explore and evaluate opportunities and resources
        • become familiar with state and federal agriculture programs.

Growing Places will be offered at three locations this fall: Berlin, St. Johnsbury & Rutland.

To register, fill it out this form and return it to WAgN by the deadline for the location you desire. The more specific your answers are, the more we will be able to meet your individual needs. Save by registering early! The regular registration fee is $125; early bird registration is $100. Your fee must accompany your registration form. Registration deadlines and fees are as follows:

Location	Time	Regular Registration Deadline	Fee	Early Bird Deadline	Early Bird Fee
Berlin	6 Thursdays, 5-8 pm	Sept. 15	$125	August 19	$100
St. Johnsbury	6 Fridays, 9 am-noon	Sept. 15	$125	August 19	$100
Rutland	3 Saturdays , 9:30 am-3:30	Oct. 1	$125	Sept. 16	$100

Make check or money order payable to UVM Extension System and mail to: Women's Agricultural Network, 617 Comstock Rd., Suite 5., Berlin, VT 05602. You will receive confirmation of your registration along with some pre-class information. Individuals requiring special accommodations or financial assistance to participate in this program should contact the Women's Agricultural Network Main Office at (802) 223-2389 x 15.

1. Today's date: __/__/__ 2. Date of birth: __/__/__

3. Name:__________________________________ ______________________________

First Last

4. Mailing Address: ___________________________________________________________

(Street/Box #)

__________________________________________________________

(Town/City) State Zip

5. County of Residence: _____________________________________________

6. Phone Number(s): ________________________ _____________________________

(Day) (Evening)

E-mail: _____________________________________________

7. I am: ___Female ___Male

8. I am (check all that apply):

___African American ___Alaskan Native ___Native American

___Asian ___Hispanic ___Pacific Islander

___Other___________________________________________

9. Please check one of the following:

(a) ___I have started an agriculture-related business already

(b) ___I have an idea for an agriculture-related business. Please describe

_______________________________________________________________________________________________

(product name)

Fill in number 10-12 only if you have started an ag-related business:

10. Business Name: _____________________________________________________

11. Business Address: ___________________________________________________

Street/Box Town/City State Zip

12. Business Phone: __________________ E-mail: ____________________________

13. I have business experience: ___yes ___no

If yes, please explain: _________________________________________________________________________

14. If you have business knowledge or training, land, available savings, favorable loan status with a lender, and/or one or more advisor/mentor(s), you have valuable resources. Please describe your available resources:

______________________________________________________________________________________________

15. What is/are the greatest barrier(s) you face in starting or maintaining your business? (These barriers could be loans and lenders; being outside information loops for programs or assistance; lack of information regarding ag policy and policy-making; or any number of other obstacles in your way) Please think carefully about the barriers in your own situation and comment briefly.

_____________________________________________________________________________________________

16. How did you hear about Growing Places? Please be as specific as possible.

_____________________________________________________________________________________________

17. Circle the Growing Places Course/Location you want to attend:

Berlin: Six Thursday evenings 5-8 pm
September 15, 22
October 6, 13 & 27
& November 3

St. Johnsbury : Six Friday mornings, 9 am to noon
September 16, 23
October 7, 14, & 28
and November 4

Rutland: Three Saturdays, 9:30 am to 3:30 pm
October 29, November 5 & 12

The United States Department of Agriculture (USDA) prohibits discrimination in its programs on the basis or farce, color, national origin, sex, religion, age, disability, political beliefs and marital or familial status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape,etc.) should contact the USDA Office of Communications at (202)720-2791.