Sign up for the Healthy Food program

Name*

First Name Last Name

Year of Birth*

Address*

Street Address City State ZIP Code

Mailing Address

Mailing Address is the same as street address

Mailing Address

Street Address Address Line 2 City State ZIP Code

Email Address*

Enter Email Confirm Email

Phone*

Term*

Is this a new or renewal supporting membership?*

New
Renewal

If this is a renewal, enter Member Number if you know it

Healthy Food Program*

I can pick up a brown bag of groceries at a site near my home
I do not wish to receive a brown bag, but I want to support Grey Bears
Please deliver a bag to my home because:

(reason)*

I am legally blind
I use a wheelchair or walker
I have a heart/lung condition
I walk with difficulty
I am isolated and can't drive
Other (describe below)

Other reason*

To comply with grant requirements please check the appropriate box (we never share your personal information):

Gender*

Male
Female

How do you identify yourself?*

Other:*

Do you identify as LGBT?*

Yes
No

Language*

I can speak English
Sólo hablo español.

Number in household*

I live alone
I live with another
We have a 3 member household
We have a 4 member household
More than 4 people in household

Monthly Income (1 person)*

$1,012 or less (yearly $12,140 or less)
$2,023 or less (yearly $24,280 or less)
My income is above these amounts

Combined monthy income (2 people)*

$1,372 or less (yearly $16,460 or less)
$2,743 or less (yearly $32,920 or less)
Our income is above these amounts

Combined monthly income (3 member household)*

$1,732 or less (yearly $20,780 or less)
$3,463 or less (yearly $41,560 or less)
Our income is above these amounts

Combined monthly income (4 member household

$2,092 or less (yearly $25,100 or less)
$4,183 or less (yearly $50,200 or less)
Our income is above these amounts

Monthly income (more than 4 in household)*

Please help us improve the program by answering a few questions. We will also follow up with you in about six months.

How many servings of vegetables and fruits do you eat each day?*

I want to participate in this program to... (check all that apply)*

Save money on food costs
Access fresh produce and healthy staples
Socialize with others
Support the program
Other

Other reason for enrolling in the Brown Bag program*

Over the last 12 months would you say your health has been…

Sign up for the Healthy Food program

Sign Up or Renew Now

Step 1 of 2

To comply with grant requirements please check the appropriate box (we never share your personal information):

Healthy Food Program

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