FreshRx for MOMs Referral Form

FreshRx for MOMs Referral Form

The FreshRx for MOMs program gives pregnant moms on Medicaid $26/ week for 40 weeks to buy fresh fruits and vegetables (plus $5 extra for any food!) at the Franklin County Farmers Market and Locals Food Hub. After submitting this form, participants come to the Market or Food Hub to finish enrolling in the program and receive tokens to spend!
Nota: si necesita traducción al español, haga clic en la pestaña de idioma en la esquina superior derecha
Participant Name*

First NameLast Name
Participant Phone Number*
Please enter a valid phone number.
Participant Email*
example@example.com
Can we contact you with reminders?

TextEmailNo
What is your preferred language?
Please check boxes to confirm that the participant is*

Currently pregnant (32 weeks or earlier)Currently enrolled in MedicaidAttending appointments with a doctor or midwife
Participant Due Date*
How did you hear about this program/ who referred you?*
Ex: name of your doctor, person who sent you the information
Clinic/ Agency of Referring Provider
Example: Family Resources, midwife, physician, etc.
FreshRx for MOMs is a collaboration of the Franklin County Farmers Market, Locals Food Hub, and Community Farm Alliance, funded by a USDA/NIFA GusNIP grant. All personal information is confidential. Aggregated data (anonymized, with no individual names or identifying information attached) will be used for reporting and evaluation and potentially shared publicly for educational or fundraising purposes.
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FreshRx for MOMs Referral Form

Nota: si necesita traducción al español, haga clic en la pestaña de idioma en la esquina superior derecha