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Luz del Corazon FARM - Grow with us! Luz del Corazon Farm Fellow Program Application Please type or print legibly. Email application to: malathy@weuplift.us

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SECTON 1: PERSONAL INFORMATION 1.1 PERSONAL INFORMATION Last Name (Surname)

First Name

Middle Name(s)

_____________________________ ________________ ____________________ Spiritual name (if applicable) : ________________________________________  Male  Female

 Single  Married

Home Telephone No.

Work Telephone No.

Home Mailing Address Date of Birth (mm/dd/yy)

Fax No./Skype Name Email Address

City and Country of Birth

Present Nationality(ies)

1.2 SPECIAL SKILLS Agriculture includes a number of skills, such as plumbing, carpentry, team leadership, and computer work. Please list your skills, e.g., farming, environmental education, carpentry, etc. Skill

Rate skill level on a scale of 1-5 (1 = low, 5 = high)

Luz del Corazon Farm Fellow Program - Application

Skill

Rate skill level on a scale of 1-5 (1 = low, 5 = high)

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1. What is it that calls you most to apply for this program? What do you hope to give and receive in this experience?

2. Describe your experience in farm and land management work.

3. Describe your experience with group or communal living.

4. Please give us a little background on your experience, if any, with formal meditation or mindfulness practice.

5. Do you have a current driver’s license? __________Can you drive a stick shift? ___________ Health Background 6. Do you have any physical or psychological difficulties that might affect your participation in the program? If so please briefly explain.

7. Do you regularly use any prescription medications? If so, please list those.

8. Do you have any dietary restrictions or allergies? Please explain.

Luz del Corazon Farm Fellow Program - Application

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SECTON 2: EMPLOYMENT AND/OR WORK EXPERIENCE, EDUCATION 2.1 EMPLOYMENT List below every employment over the last five years. If you need additional space, attach a separate sheet with your name on it. Present or Most Recent Position Name of Organization

Name and Title of Supervisor

Position Title

Telephone and Email of Supervisor or organization

Dates of Employment (Month/Year) From: To:

Nature of Organization

Reason for Leaving Duties: Describe concisely work undertaken, including accomplishments, responsibilities and teaching duties, if any

Next Most Recent Position Name of Organization

Name and Title of Supervisor

Position Title

Telephone and Email of Supervisor or organization

Dates of Employment (Month/Year) From: To:

Nature of Organization

Reason for Leaving Duties: Describe concisely work undertaken, including accomplishments, responsibilities and teaching duties, if any

Luz del Corazon Farm Fellow Program - Application

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Next Most Recent Position Name of Organization

Name and Title of Supervisor

Position Title

Telephone and Email of Supervisor or organization

Dates of Employment (Month/Year) From: To:

Nature of Organization

Reason for Leaving Duties: Describe concisely work undertaken, including accomplishments, responsibilities and teaching duties, if any

2.2 EDUCATION (include current enrollment) Institution Name, City and State

From

To

Degree/Diploma

Date Completed

Field(s) of Study

University or equivalent

Technical training, apprenticeships

Luz del Corazon Farm Fellow Program - Application

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SECTON 3: FINAL INFORMATION 3.1 REFERENCES List three work references (employers, professors, supervisors) who will provide a recommendation for you. Name

Telephone

Email

Business or Occupation

3.2 Anything else we should know about you? Please feel free to comment here.

3.3 CERTIFICATION I certify that the statements made by me are true to the best of my knowledge and belief and that willful misstatement may lead to disqualification or revoking of the fellowship.

Signature _________________________________________

Luz del Corazon Farm Fellow Program - Application

Date ________________________

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2014 Luz del Corazon Farm Fellow Application  
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