Project MANNA: Sign Up Form
✨We provide fresh, healthy, and culturally relevant foods to Black mothers at no cost—sourced from local Black farmers in Appalachia—promoting wellness, food justice, and community care.
Participant Information
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
*
Please Select
Newspaper
Internet
Printed Flyers
Other
Please Specify
*
Are you currently pregnant or have given birth within the last 12 months?
*
Yes
No
Do you have any dietary restrictions /allergies that you would like to share?
*
Yes
No
Would you like to receive text/email reminders?
Yes
No
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