SNAP Sign-Up Form for Harvest Box Program
Program runs for 16 weeks - July 1st to October 14th - boxes ready on Wednesday for pick-up or delivery
Please fill out this form if you are a SNAP eligible customer who wants to participate in our Harvest Box Program!
Email delaney@klamathgrown.org with questions!
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
We are offering two different share options. Details below!
1. Classic Box: a selection of fresh fruits & vegetables - $72 a month charged on your SNAP card for the 4 month season - $288 total
This box is eligible to use Double Up Food Bucks to match half the cost, prices reflected above.
2. Specialty Box: the Classic Box items PLUS meat, bread and eggs - $141 a month charged on your SNAP card for the 4 month season - $564 total
This box is eligible to use Double Up Food Bucks to match half the cost, prices reflected above.
What type of box would you like to purchase with SNAP funds?
Please Select
Classic Box
Specialty Box
Pick Up OR Delivery Options- please choose one option that works best for you and your schedule through the whole season July-October.
***All deliveries are FREE of charge within 25 miles of Mills Neighborhood
Pick-Up Locations: please choose the location below if you would like to pick up your box each, please pay attention to days & times at each location!
I would like my box delivered (must be within 25 miles of Mills Neighborhood)
I would like to pick-up at Klamath Grown Main Location: Wed ONLY 4-7pm, 601 East Main St.
I would like to pick-up at NW Makers Market: Wed after 4pm or Thurs-Sun 10am-6pm, 133 S 9th St.
I would like to pick-up at Sky Lakes Medical Center Bistro: Wed ONLY 4:30-8pm, 2865 Daggett Ave.
I would like to pick-up at Running Y Resort Sport & Fitness Center: Wed ONLY 5:30-6:30pm, 5271 Cooper's Hawk Rd.
If you would like your box delivered directly to your home, please write your address below:
We ask that you only commit to this program if you're willing to participate for the entire summer. The farmers we work with depend on this program for their business. Please sign below that you agree to join this program for the entire 4 months this summer.
You will be emailed an agreement from our partner organization Pacific Northwest CSA Coalition. They will be processing your SNAP payments. In what language would you like your agreement and emails?
English
Spanish
If you are unable to receive emails due to internet/computer access please select this option and we will reach out
How did you hear about the Harvest Box Program?
PNW CSA Coalition Website
DHS/WIC Office
Medical Provider
Friend or Family Member
Social Media
Newspaper Ad
Other
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