| Ecofarm Questionnaire |
| Name |
| Age & Birthdate |
| Drivers Licence # Social Security # |
| Address |
| Phone Number Email |
| Emergency Contact |
| Purpose of visit |
| Are you covered by any health insurance ? Have you been convicted of a felony ? Do you have any allergies/special needs ? Do you have any medical problems ? Do you have any debts ? Do you have pets that you wish to bring ? Are you financially able to travel to and from Ecofarm ? If you answered yes to any of the above, please explain below |
| By signing below I understand that while at Ecofarm I am a visitor and agree to follow the polices provided by Ecofarm. I also understand that I am not being provided any health insurance or medical coverage by Ecofarm during my stay. Name Date Signature |