Regenerator Waitlist

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Waitlist
Thank you for your interest in the Regenerator Program!

First Name:

Last Name:

Email:

Phone Number:

Type of phone

MobileWorkHome

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Your Farm/Ranch
/Business Name

County where your farm/ranch/business is located

Do you have an identified successor for your farm/ranch business?

YesNoUnsure

Demographic information:

California FarmLink collects this data for aggregate reporting purposes, which helps us to better understand the communities we serve. Thank you

A member of household is a dependent relative or dependent non-relative that resides in your residence.

How many people are in your household? (Including yourself)

Birthdate (mm/dd/yyyy):

Are you a veteran of the United States Armed Forces?

YesNoPrefer not to say

What branch of the military?

What is/was your highest rank in the military?

What is your current military status?

Are you eligible for military educational benefits?

Which gender identity
best describes you?

WomanManGender Nonconforming/Gender VariantTransgender ManTransgender WomanPrefer Not To Say

Do you identify as LGBTQ+ ?

Race/Ethnicity:

Alaska NativeNative AmericanAsian AmericanBlack or African AmericanHispanicMiddle Eastern or North AfricanNative HawaiianOther Pacific IslanderOtherPrefer Not to SayWhite

Ethnicity (Other):

Preferred Language:

Language (Other):

What is your country of origin?

Do you have official refugee status under the United States
Refugee Admissions Program?

Do you have any disability?

Do you receive disability benefits?

How did you hear about us?

Other:

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Contact Information