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Registration Form

Name *

First

Last

How did you hear about Farm to Families?

Gender

Female
Male
Other

Birth Date *//

Total number of people in your household? *

How many of them are children? *

Please check the box next to your annual household income level

No Income
$0 – $35,310
$35,311 – $47,790
$47,791 – $60,270
$60,271 – $72,750
$72,751 – $85,230
$85,231 – $97,710
$97,711 – $110,190
$110,191 and above

Please indicate if you are:

Currently enrolled as a student
A senior citizen (age 65+)
Permanently disabled
Currently receive food assistance (SNAP/Food Stamps, WIC, etc.)
Referred by healthcare provider

Name of the practice of the healthcare provider that referred you

Please read the following statements and indicate whether you AGREE or DISAGREE (according to your household’s situation).

Within the past 12 months, I worried about whether my food would run out before I got money to buy more. *

Agree
Disagree

Within the past 12 months, the food I bought just didn’t last and I didn’t have money to buy more. *

Agree
Disagree

Which site would you prefer to join? (click the dropdown arrow to select)

Mobile Phone *

Alternate Phone

Email Address *

Street Address *

Address Line 1

Address Line 2

City

State

Zip Code

1. By submitting this form, I certify that all of the information above is to the best of my knowledge and belief true, correct and complete.
2. By submitting this form, I agree to give up my right to a credit or replacement box in the event that I can’t pick up my order during pick-up hours.

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