Name Family Senior/Elder Are you How many in your family How many people live How many people live in pregnant? are less than 19 years old? in your household? your household? ☐ Gender ☐ ☐ Female/ Identify as female Male/Identify as male I agree to be a part of the Farmers’ Market Nutrition Coupon Program. I understand the program provides fresh, local food for those who face financial challenges. I understand that these coupons are for my family’s personal use only. _______________________________________ ________________________________ Sign here Date Area(s) of Support In what area(s) could you and your family benefit from support while in the coupon program? Skill and Experience in Preparing Food Organizational Skills & Experience Food preparation using utensils and appliances Preserving foods such as canning or freezing Following instructions in recipes Buying healthy food while on a budget Improvising with ingredients Buying and storing foods Knowing Nutritious Food Planning healthy meals More confidence to make healthy meals Information about food and nutrition Personal and Social Factors How to read food labels More confidence buying healthy food Where does food comes from Connecting to other people in my community Cooking food and storing food safely to prevent Feeling healthier food related illnesses Other Area of support How shopping at a farmers’ market impacts your community Making healthy food Help Us Evaluate the Program (optional) We would like to send you a survey to ask about the program. Please provide us with your email address. We will not share your personal information. Address
Name Family Senior/Elder Are you pregnant? How many in your family are less than 19 years old? How many people live in your household? How many people live in your household? ☐ Gender ☐ Female/ Identify as female ☐ Male/Identify as male I agree to be a part of the Farmers’ Market Nutrition Coupon Program. I understand the program provides fresh, local food for those who face financial challenges. I understand that these coupons are for my family’s personal use only. _______________________________________ ________________________________ Sign here Date Area(s) of Support In what area(s) could you and your family benefit from support while in the coupon program? Skill and Experience in Preparing Food Food preparation using utensils and appliances Following instructions in recipes Improvising with ingredients Knowing Nutritious Food Information about food and nutrition How to read food labels Where does food comes from Cooking food and storing food safely to prevent food related illnesses How shopping at a farmers’ market impacts your community Making healthy food Organizational Skills & Experience Preserving foods such as canning or freezing Buying healthy food while on a budget Buying and storing foods Planning healthy meals More confidence to make healthy meals Personal and Social Factors More confidence buying healthy food Connecting to other people in my community Feeling healthier Other Area of support Help Us Evaluate the Program (optional) We would like to send you a survey to ask about the program. Please provide us with your email address. We will not share your personal information. Address
2017EnrollmentFormFINAL(1).docx