Farm to Fam Program Household Application

Farm to Fam Program Household Application

Thank you for your interest in the Farm to Fam Program, which provides fresh local food boxes to families in our community. Please complete this application so we can better understand your household's needs. Completing this form does not guarantee acceptance, as participation depends on available funding and food supply.
Section 1 — Applicant Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address *
example@example.com
PhoneTextEmail
Section 2 — Household Information
Number of Adults in Household*
Number of Children in Household*
Ages of Children
YesNo
Total Number of People in Household*
Section 3 — Food Needs
YesNo
If yes, please list
VegetarianVeganGluten FreeDairy FreeNoneOther
Fresh vegetablesFruitsEggsMeatBreadPantry items
Other helpful foods
Section 4 — Household Financial Snapshot
Employed full-timeEmployed part-timeSelf-employedCurrently seeking employmentUnable to workRetired
Under $20,000$20,000 – $40,000$40,000 – $60,000$60,000+
SNAP / Food StampsWICFree or Reduced School Lunch programDisability benefitsOther assistanceNone
Section 5 — Transportation

To qualify, you must have reliable transportation and be able to pick up at 515 North Commerce Avenue, Front Royal, VA 22630. At this time, we are unable to offer delivery services.
YesNo
Section 6 — Volunteer & Community Participation
YesNoMaybe occasionally
Helping pack food boxesHelping with deliveryHelping at community eventsGardening or farming helpHelping other families
WeekdaysEveningsWeekendsOccasionally
Section 7 — Skills & Talents
Do you or anyone in your household have skills you would be willing to share with the community? Examples: gardening, cooking, carpentry, art, teaching, childcare, repair work.
Section 8 — Program Impact
How would receiving Farm to Fam food boxes help your household?
Section 9 — Optional Demographic Information
Single parent householdVeteran householdHousehold with disabilitySenior householdNone of the above
Section 10 — Referral Source
Friend / FamilySocial MediaLocal schoolChurchCommunity organizationEvent or farmers marketOther
Section 11 — Agreement
I understand The Farm to Fam program depends on donations, grants, and food availability.

Completing this application does not guarantee acceptance.

Information may be used for anonymous reporting to program sponsors and grant providers
Signature*

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Farm to Fam Program Household Application

Section 1 — Applicant Information

Section 2 — Household Information

Section 3 — Food Needs

Section 4 — Household Financial Snapshot

Section 5 — Transportation

Section 6 — Volunteer & Community Participation

Section 7 — Skills & Talents

Section 8 — Program Impact

Section 9 — Optional Demographic Information

Section 10 — Referral Source

Section 11 — Agreement