First Name
*
Last Name
*
Email
Phone
*
(###)
###
####
Street Address
*
City
*
State
*
Zip Code
*
Household Size - Number of Adults
*
1
2
3
4
5
6
7
8
Household Size - Number of Children
*
0
1
2
3
4
5
6
7
8
9
Race
(optional - check all that apply)
Employment Status
*
Annual Household Income
*
$0 to 30,000
$30,000 to 60,000
$60,000 to 90,000
$90,000 to 120,000
$120,000+
Do you use any of these medical providers?
*
Check all that apply
Within the past year, have you used any of these services?
*
Check all that apply
Within the past year, have you used any of the services provided by these organizations?
*
Check all that apply
If choosing "Other" please enter the name(s) of the organization(s) here
What, if any, of the following challenges do you face that make it difficult to regularly eat fresh, healthy food?
*
Check all that apply
If choosing "Other" please tell us more here
What kind of internet access do you have?
*
Check all that apply
If choosing "Other" please tell us more here
Will you be able to get to the farm to pick up your share every other Wednesday?
*
Are you interested in trying new vegetables?
*
How will having this CSA share help you?
*
Additional Information
If you'd like to clarify any of your answers above, or have anything else you'd like us to know, please tell us here.
Have you ever taken one of our FreshRx classes?
*
If yes, what year was your class?
