Master Gardener Program Interest Form

I request acceptance into the 40-hour County Master Gardener training program offered by the University of Arkansas System Division of Agriculture Cooperative Extension Service (UADA).

• I am able to complete the entire training session for which I am approved.
• I also agree to pay the training fee which covers training materials, county-specific items, nametag, and first year’s dues.
• I understand that I will become a Master Gardener when I complete the 40-hour training and pass the examination.
• In exchange for the training, I will volunteer at least 40 working hours AND acquire 20 additional learning hours in the County Master Gardener program within the first year.

To retain the Master Gardener designation in each subsequent year, I will:

Volunteer at least 20 working hours AND obtain 20 additional learning hours in your County
Pay annual dues
Once your application is received, a Master Gardener will contact you with the current class options.

Name*

First Name

Last Name

What name do you prefer to be called?

Date of Birth

Home Phone Number

Cell Phone Number*

E-Mail Address*

Street Address*

City*

State*

Zip Code*

County

Did the zip code reflect the correct county? If you do not see your county listed after zip code, select no and enter the correct county in the next question.*

Yes No

Please enter the correct county and state if applicable.*

Emergency Contact Information

Emergency Contact Name

First Name

Last Name

Relationship

Emergency Contact Phone Number

Gardening Experience

Years of Gardening Experience*

Type of Gardening Experience

List areas of specialty or hobbies (e.g., flowers, herbs, ornamentals)

List experiences working with the community (e.g., schools, churches, youth, senior citizens)

List garden related affiliations (e.g., garden clubs, plant societies)

How did you learn about the Master Gardener program?

Why do you want to become a Master Gardener?

Additional Comments

Acknowledgement and Signature

We will collect, process, and/or use the personal data that you supply to us on your application. This may include from you: your name, address, phone number, e-mail, and other contact information, as well as licenses, certifications, education transcripts, visa, passport, and additional information regarding your qualifications as a Master Gardener. I understand that the information provided in this application will be used by University of Arkansas Division of Agriculture (UADA) for the purposes of administrating the Arkansas Master Gardener Program.

I consent to the routine use of the information provided herein for the use of the UADA to administer its Master Gardener program.

I certify that the information I have given is accurate to my knowledge.

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Use your mouse on a desktop or your finger on a touchscreen to draw your signature above

For more information, please contact your County Agent.

Date Sent to Corresponding Secretary

The University of Arkansas System Division of Agriculture offers all its Extension and Research programs and services without regard to race, color, sex, gender identity, sexual orientation, national origin, religion, age, disability, marital or veteran status, genetic information, or any other legally protected status, and is an Affirmative Action/Equal Opportunity Employer.