Access Program Sign-Up / Renewal Form

Access Program Sign-Up / Renewal Form
Owner Name:*

First NameLast Name
Owner Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Have you participated in the Access Program before?*

YesNo
How did you hear about the Access Program?*

As a New OwnerAt CheckoutAt an EventReaderOnlineWord of MouthIn an AdvertisementOther
Terms of Service:
- I certify the qualifications for the Access Program I selected on this form and I understand that the Willy Street Co-op will cancel my Access Program benefits if I do not select my qualifications honestly. I understand that Willy Street Co-op may ask me to provide proof of qualification or participation in a qualifying benefit or assistance program for any reason at any time.
- I agree to contact Willy Street Co-op to update my Ownership information if my name, address, phone or email address changes.
- I understand that I am responsible for what I buy and that I can only buy food and products that will be used in my home, by me and my family. I agree not to share my discount with anyone that is not listed on my Ownership account. I understand that if I use the Access Discount inappropriately (for example, if I use my discount to buy products for other people that are not on my account) the Willy Street Co-op will cancel my Access Program benefits.
- I understand that my Access Program benefits will expire on the following March 31st if I do not renew my qualifications for the Access Program. I understand I must renew my qualifications for the Access Program every year by March 31st so that the Willy Street Co-op does not cancel my Access Program benefits.
Signature*
For privacy, only the above part of the form will be scanned and filed into the Owner's records. The paper copy of this form will be destroyed following application processing. If you would like a copy of this form on paper or electronically, please ask Customer Service
Qualifications for the Access Program
Signing above means that you are self-certifying that the information you provided is true. Willy Street Co-op reserves the right to request proof of qualification or participation in a qualifying benefit or assistance program for any reason at any time.
Please choose one of the two qualifier types below to certify you need the Access Program.
Option 1: I am receiving benefits or assistance from one or more of the following programs or have received benefits or assistance from one or more of the following programs within the last three months:

QUEST FoodShare Program (SNAP)Medicaid (BadgerCare/Senior Care)Special Supplemental Program for Women, Infants and Children (WIC)Section 8 Housing Assistance/Community Development Authority (HUD)Senior Farmers' Market Nutrition ProgramSupplemental Security Income (SSI)Social Security Disability Insurance (SSDI)Low Income Home Energy Assistance ProgramFairShare CSA Coalition Partner SharesFree or Reduced Lunch and Breakfast ProgramWisconsin Shares Child Care Subsidy ProgramWisconsin Works (W-2) (TANF)Early Head Start/Head StartHeat for HeroesVA Disability
Option 2: My annual gross income within the last year was at or below 150% of the Federal Poverty Guideline for the number of persons in my family/household (see chart below for guidelines).

YesNo
Should be Empty:

Access Program Sign-Up / Renewal Form

Qualifications for the Access Program

Please choose one of the two qualifier types below to certify you need the Access Program.