Application Date:

Primary Contact Person: Legal name, nick name, age and any health concerns

  1.

Primary

Contact's

Address

Street/ PO Box

City State Zip

Phones

Home

Work

Cell

Email

Name or nickname and ages of all other keepers in party.

Indicate relationship to contact person or each other  (married, partner, son, daughter, aunt, etc.)

Health concerns (asthma, diabetes, hearing aid, pregnant, obese, recent surgery, smoker, etc.)

 Name / Age

 2.

 3.

 4.

 5.

 6.

 Relationship

 2.

 3.

 4.

 5.

 6.

 Health Concerns / Smoker?

2.

 3.

 4.

 5.

 6.

Total number of keepers

    ____ Adults   _____ Children (under 18 yrs.)  = _______ Total

Person to notify in case of emergency

  Name / Relationship:                                                            Phone:

Health / Accident Insurance Carrier

List weeks in order of preference. Call to make your reservation, then send your application to complete the process.

      List desired weeks in order of preference                 Full Time            Vacationing
                                                                                                    Keeper*                Keeper

 1.    ________________________             __________       __________

 2.    ________________________             __________       __________

 3.    ________________________             __________       __________

 4.    ________________________             __________       __________

*Full Time Keepers can deduct expenses as a charitable contribution by working 6-8 hours per day.  We will work with you to plan projects that make the best use of your skills and our needs (indicate skills for each person in your party below). You will document your "tour of duty" with before-and-after photos, plus log book entries. Make copies for yourself and for us. When we receive our copy, we will acknowledge your program fee as a tax-deductible contribution. See IRS Publication 526.

Skills & Experience

Write each person's name on the top line and indicate their skill level in the column opposite each skill

 0 = No skill or interest
 1 = Willing to learn
 2 = Beginner
 3 = Pretty good
 4 = Professional

KEEPER NAME

1.

2.

3.

4.

5.

6.

 Carpentry

 Roofing

 Masonry

 Painting

 Welding

 Gardening

 Tree work

 Cleaning

 Retail Sales

 Tour Guide

 Sewing

 Civil Engineering

 Good Helper

Other skills & remarks: Do you own your own house? Not afraid to get dirty? Do windows? Ok on ladders? Have you been a keeper or stayed overnight before?