Garden Harvest Registration Form

Garden Harvest Registration Form

To receive produce from our seasonal harvest, please complete this form.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail
How did you hear about us?*
Specify the other way in which you heard about this program.
How many people reside in your household?*
(Other) If your household has more than seven people, please specify.
YesNo
YesNo
Has your household experienced any food shortage in the past year?*
If you answered no to the above questions, please provide your yearly household income?*
What is your ethnicity?*
Which school does your child(ren) attend?*
(Other) If your school is not listed above, please provide school name here.
If your child does not attend school in DeKalb County, please provide school name and the county where it is located.
What is your student's grade level*
Do you have any food allergies?*
Please list any vegetables that you or someone in your household may be allergic to.
Would you like to subscribe to our email list to be notified about upcoming virtual youth programs and events being offered by EBLLC or opt-in to participating in a survey?*
Please verify that you are human*
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