Neighbor Questionnaire

Name:
Address:
Phone number:
Email address:

Would you like to join a neighborhood email listserv? _Yes _No

Emergency contact (someone we can call if we think you need emergency help):

Home phone:_______ Work phone:_______ Cell phone:_______

How long have you lived in this neighborhood?

Where are you from originally?

What do you like to do for fun?

What kind of work do you do?

What city do you work in?

Do you drive to work? _Yes _No

Would you be interested in carpooling if a neighbor works near you? _Yes _No

Do you own a car? _Yes _No

Would you ever be interested in sharing a car with a neighbor? _Yes _No

If you work from home, are you interested in sharing office equipment? _Yes _No

Do you have children? _Yes _No

If so, how many and how old?

Would you ever like to trade child care with other neighbors, whether through casual babysitting, sharing a child care provider, or otherwise? _Yes _No

Do you have pets? _Yes _No
If so, who are they?

Would you ever like to coordinate with neighbors to take turns walking dogs or caring for other animals? _Yes _No

Would you be interested in joining a neighborhood gardening group? _Yes _No

Would you be interested in joining a neighborhood home improvement group, which will meet to work on home repair and building projects at each member's house? _Yes _No

Would you like to be invited to neighborhood games nights? _Yes _No

Would you be interested in doing mealsharing with neighbors? _Yes _No

Do you have a fruit tree that you'd like help harvesting or fruit you'd like help eating? _Yes _No

Do you or does anyone in your household have any disabilities or health problems you would like your neighbors to know about, or you might need help with? _Yes _No

If so, what are they?

Would you be interested in sharing any of the following:
_ Tools, ladders, etc.
_ Washer and dryer
_ Household appliances, like vacuum cleaners
_ Household goods and electronics
_ Toys and sports equipment

Rate each of the following priorities by circling a number (1 = least important; 5 = most important).

The Space:

Material Needs and Long Range Plans:

Furnishings I own and could share include:

Furnishings I need or would like to have include:

Home Environment, People, and Lifestyle:

Other wants and needs:

Home Improvement Group: Tools and Skills Assessment

Name(s):______________________________

Address:______________________________

Phone:_______________ Email: _______________

Preferred Work Day (check one): __ Saturday __ Sunday

Tools I Have for the Group to Use:

__ Basic garden tools
__ Basic hand tools
__ Saw(s)
__ Drill
__ Ladder(s)
__ ____________________
__ ____________________

Possible Projects for Our Household

1. _______________
2. ______________
3. ______________

Diet Preferences for Mealsharing

Fruit Harvest Agreement

This agreement is between the Neighborhood Fruit Harvest Group ("Harvesters") and __________ ("Owner"). We enter into this agreement to allow Harvesters to pick fruit from Owner's fruit tree(s) and bushes.

1. On the following dates and times, Harvesters will pick the following fruit:

[Date]: Harvesters will pick_____________.
[Date]: Harvesters will pick_____________.
[Date]: Harvesters will pick_____________.

2. Check one of the following:

     __ It is ok for Harvesters to enter the yard when Owner is not home. If owner is not home, Harvesters should [describe procedures, such as "close the gate behind them."]

     __ Harvesters should enter the yard only when Owner is at home.

3. Harvesters will follow these rules when in Owner's yard: [describe rules, such as "Harvesters will not smoke;" "Harvesters will not make unnecessary noise while in the yard;" "Harvesters will take care to not damage flower beds or break any branches of the fruit trees."]

4. Harvesters will pick all fruit that appears ready to be picked and leave less mature fruit on the tree.

5. Harvesters will take care to avoid damaging the tree or breaking branches.

6. Harvesters will give [amount] of fruit to Owner.

7. Harvesters may do the following with the remainder of the fruit. (Check all that apply.)

     __ Give fruit to other neighbors

     __ Donate fruit to a food bank or other charity

     __ Consume the fruit

     __ Preserve or prepare the fruit, to eat or share

8. Harvesters will take reasonable steps to ensure that the fruit is not wasted.

9. Harvesters will use all proper care and safety precautions when climbing trees and ladders. ( Or: Harvesters will not climb the trees or use ladders. Harvesters will use extension fruit pickers, which they will provide.)

10. Owner does not ask for any compensation.

11. Harvesters, as consideration for the right to harvest fruit from Owner's tree(s), agree not to make a claim against or sue Owner for injury, loss, or damage that occurs during fruit harvest and/or consumption of Owner's fruit, including injury, loss, or damage arising from the negligence of Owner. Harvesters agree to indemnify, hold harmless, and defend Owner from all claims, liability, or demands that Harvesters or any third party may have or in the future make against Owner for injury, loss, or damage arising from harvesting and/or consuming fruit from Owner's trees, including from food-borne illness.

HARVESTERS:
Name:_____________________ on behalf of ________________
Signature:________________
Date:_____________________

OWNER(S):
Name:_____________________
Signature:________________
Date:___________
Name:_____________________
Signature:________________
Date:___________

Information Sheet for Children's Carpool

Child's Name:____________________________
Address for Pickup:________________________
Parent/Guardian Names:___________________

Parent 1:___________________________
Phone (please put a checkmark by the best number to reach you)
__ Home:__________ __ Work:___________
__ Cell:____________ __ Other:__________
Email:____________________

Parent 2:___________________________
Phone (please put a checkmark by the best number to reach you)
__ Home:__________ __ Work:___________
__ Cell:____________ __ Other:__________
Email:____________________

Name of Parent Who Will Drive Carpool:______________
Drivers' license no.:__________
Car make/model:____________ License plate:_________
Insurance co.:______________ Policy number:_________

Emergency Contact Name:______________________
Relationship to child:__________________________
Best number to reach:_________________________

Child's Physician Name:__________________
Best number to reach:___________________

Worksheet: Annual Car Expenses

Information Sheet for Carpool Members

Name:_____________________________
Address for pickup:__________________

Phone numbers(please put a check mark by the best number to reach you)
__ Home: _________________________
__ Work: _________________________
__ Cell: __________________________
__ Other: ________________________
__ Email: ________________________

Emergency contact
Name:____________________________
Relationship:______________________
Best number to reach:_______________

Driver information
Drivers' license number:___________________
Car make and model:______________________
License plate:____________________________
Insurance co. and policy number:____________

Worksheet: Work Expenses to Consider Sharing