Enroll in AgrAbility

Enrollment Form - Duplicate

Please fill out the information as best as you can. An AgrAbility staff member will call or email to follow up on your enrollment and discuss any questions we have.

"*" indicates required fields

Name*

First Last

Spouse Name

If under the age of 18, please name a guardian in this section.

Email Address

Best Phone Numbers*

Please include a home phone and/or cell phone

Date of Birth*

Gender*

Ethnicity*

Are you a Veteran?*

If yes, years served

Farm Address*

The specific address where the farm is located. Include County. Example: 1234 Creek Rd, Delavan, WI 53115 Walworth County

County*

Please list the county your farm is located in.

Mailing Address

This is not required if you live at the farm address.

Farm Position*

Years in Business*

What year did you start farming? Did you take over the farm from your parents/ family member?

Work Status*

Farm Businesses*

Please explain what is all included in the farm. How many acres you are running, any crops and animals on the farm, and any other agriculture businesses you have on the farm.

Limitations*

Explain what's not working. Are you having trouble with your arthritis acting up or not able to get in and out of tractors? If you had an injury, tell us the year it happened and any surgeries or continued therapy. INCLUDE AS MUCH DETAIL AS YOU CAN.

Name

This field is for validation purposes and should be left unchanged.