For Office Use Only

Winooski Community Gardens Plot Request Form

Deadline: April 1st, 2013

Gardener Information
Name: Address: City: Phone: State: Email: Yes Yes No No Zip:

Name:

Did you have a garden plot with this program last year? If yes, where? Landry OBrien Community Center If available, would you like to keep your current plot?

Description/Size
Landry Garden 105 ft2 Landry Garden 225 ft2 OBrien Community Center Garden 40 ft2 (4x10) Scholarship Donation

Quantity Cost
$35 $50 $10

Amount
$ $ $ $

Date Received:

Total Amount $ Landry Gardeners ONLY Please indicate below if you want a tilled (seasonal), or no-till (extended season) plot: Tilled No-Till

Scholarships
I would like to apply for a Gardeners Scholarship. Waiver:
I am fully aware of the risk inherent and hereby give my consent to participate in the program indicated. I agree to hold harmless the City of Winooski and its employees, elected officials or any paid or volunteer staff from any and all liability from any injury, claims, costs, or loss of service which might be incurred in said programs, activities, or events. I understand that medical insurance coverage is not provided. Permission is hereby granted that I may receive emergency treatment, if needed, and I authorize the attending physician to administer any necessary medical attention. Furthermore, I certify that I have no limitations except as stated above. I have read this document carefully and sign it voluntarily with full knowledge of its significance.

Assigned Plot:

Gardener Signature:

Date:

Language Sponsor
Language Sponsor Name (please print): Email: Phone: I agree to be the primary contact for this gardener and make him/her aware of all communications regarding his/her plot and the gardens in general. Language Sponsor Signature:
Please Return to: City of Winooski, 27 West Allen Street, Winooski, VT 05404, ATTN: Garden Program OR vista@winooskivt.org

Registration Information
1. Payment You do not have to submit payment with the registration. You will receive a payment notice and guideline form after you have submitted your application. 2. Scholarships The cost of a plot is 50% of the full plot fee for those who receive a scholarship. You will be notified after you submit your registration form, if you are to be awarded a scholarship. If you are not awarded a scholarship, you will be billed for the full plot fee. We also welcome donations to the scholarship fund; they are greatly appreciated and help make the gardens accessible to all. 3. Language Sponsor If you are working with someone to help translate this registration form, please provide the name and contact information of that person. Please contact us if this information changes at all throughout the season. If you are translating this form for a gardener, we may ask you to relay or translate notices to the gardener(s) throughout the season to ensure that important information reaches all gardeners. Your cooperation is greatly appreciated. 4. Plots Please note that plot positions may shift at the OBrien Community Center Garden. We will try to put you as close to your original plot as possible if you would like to keep your plot from last season. 5. Questions or concerns Contact the Winooski Community Gardens Program at: vista@winooskivt.org or (802) 655-6410 ex 12

OBrien Community Center Garden

Updated February 15, 2013

Please Return to: City of Winooski, 27 West Allen Street, Winooski, VT 05404, ATTN: Garden Program OR vista@winooskivt.org