Name________________________________________________Phone___________________________

Address______________________________________________________________________________

City_____________________________________________State_________________Zip____________

E-mail_______________________________________________________________________________

What is the general time frame or specific dates (if known) that you prefer to arrive? _______________________________

Please list a secondary time or date if possible_________________________________________

For how long can you stay?________________________ (A month stay is preferred for you to get the routine down and is easier on the family. If you are unable to stay a month, check in with BMIS for possible arrangements. Work crews are encouraged to stay around a week and be well organized in advance. Check in with BMIS for arrangements.)

Contact in case of emergency:

Name________________________________________________Phone___________________________

Address______________________________________________________________________________

City_____________________________________________State_________________Zip____________

E-mail_______________________________________________________________________________

Name, phone number, address, & e-mail of two personal references that you have known at least two years:

1)____________________________________________________________________________________

_____________________________________________________________Relationship_______________

2)____________________________________________________________________________________

_____________________________________________________________Relationship_______________

Do you have (or have access to) a vehicle? (If yes, what kind)?_________________________________________

Do you have any injuries or health conditions? Are you on medications? ______________________________________

_____________________________________________________________________________________

Feel free to write on another page:

How did you hear about direct, on-land support work on Black Mesa?

Why do you want to stay with a family on Black Mesa?

Will you be able to be self-sufficient for the duration of your stay on Black Mesa?

What did you find interesting about the Cultural Sensitivity & Preparedness Packet?

Share a little something about yourself.

Please let us know if you have skills in carpentry, mechanical, medical, dry gardening or permaculture, etc. (You are not required to have these skills, but it may help us place you with a particular family.)

Keep the Cultural Sensitivity & Preparedness Packet with you when you go to the land. It is required that you sign the following:

I have read and understand the cultural sensitivity packet.

I am prepared for staying with a family or elder in the remote area of Black Mesa.

I agree to bring some gas money for my ride or guide to The Land and for my own food for the duration of my stay with a host family on Black Mesa.

I agree to leave Black Mesa if the family or support group tells me to for whatever reason.

Signed:____________________________________________________Date:______________________