Brotherhood of Christ Community

Visitor Registration

 

We are glad to send you this application form and we are always glad to receive visitors.  We enjoy meeting new people and look forward to hearing back from you.  The answers you provide on this form are important to us in determining the scope of your visit and developing a relationship with you.  Your answers will not be shared with others.

 

Date: __________________________

 

Name (first, middle, last)  __________________________________________

Date of Birth _____________________ SS# ____________________ Are you a U.S. citizen? ___________

 

Do you have any criminal record? If so explain:_______________________________________________

Do you have any history of mental illness?  If so explain: ________________________________________

Do you have any history of anger issues?  Explain: _____________________________________________

Have you ever lived in a community before?  If so, which one(s): __________________________________

Do you smoke or use recreational drugs (including alcohol)? _____________________________________

 

Marital Status:     Single,    Married,     Single Parent,       Separated/Divorced

Do you have any custody related issues for any children that may be living with you? __________________

Do you have any specialized skills that may contribute to community? ______________________________

­­­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________________________

 

Current Address:               Street___________________________

                                          City _____________________ State _________   Zip ______________

 

Previous address:              Street___________________________

                                          City _____________________ State _________   Zip ______________

 

Name of emergency contact person ________________________________________________

Their relationship to you _________________________________________________________

Phone number or email where they can be reached ____________________________________

 

If you are under 50 years of age, please fill out the following:

Mother’s Name ________________________________            Phone ____________________________

Father’s Name _________________________________           Phone ____________________________

 

Do you currently have health insurance? Yes/No

Do you have any physical limitations or restrictions that would inhibit you from working on the farm here? _______________________________________________________________________________________

 

Please list any medical needs, food allergies, health issues or medications that we should be aware of:

______________________________________________________________________________________________________________________________________________________________________________

 

If you plan to drive your own vehicle to visit please fill out the following:

Make ___________________     Model __________________     Year ______   License plate State and number _______________

 

Please list at least two character references (family, friend, co-worker) different from the above contact person who can vouch for you:

1. _______________________________________ phone number _______________________

2. _______________________________________ phone number _______________________

 

What is your religious background? ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Please tell us your main interest in visiting our Community: (use as much space as you need ) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

How long of a visit are you looking for?         3-4 days           or         6-7 days

 

What dates are you proposing as a desirable time to visit?  _________________________________________

(We do not accept visitors from April 1 – June 1)

Please consider the weather in Iowa, and your readiness for it, when choosing your visit dates.

 

Please list any other information that you feel is important for us to know about you: