Community Funded Farmshare

Name *

First Name

Last Name

Phone *

(###)

###

####

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Races / Ethnicities / Origin in your household? (check all that apply)

Black / African American / Afro-Caribbean / African

Latinx / Hispanic

Indigenous / Native

Asian descent

Multi-racial

White / European descent

I prefer not to answer

Other (specify below)

What gender(s) are in your household? (check all that apply)

Female

Male

Transgender

Queer

Gender non-conforming / Non-binary

Intersex

Other

I prefer not to answer

What is your age?

17 or younger

18-25

26-35

36-45

46-55

56-65

66-75

76 or older

Do you have access to reliable transportation? *

Yes

No, I would like help accessing my share

Are you part of the SNAP/EBT program? *

Yes

No

Would you like to apply for a full or partial scholarship? *

Full Scholarship

Partial Scholarship