Produce Perks Interest Form

Produce Perks Interest Form
Contact Information
Full Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Contact Method
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Zip Code
Neighborhood
Household Information
Number of people in your household
Do you currently have a minor child in your household?
Are you currently pregnant?
Produce Perks Eligibility
Residents may qualify for Produce Perks support if they have a child in the household or are pregnant, meet approved eligibility requirements, and have NOT enrolled in the Fruit & Vegetable Coupon/Delivery Program within the last 6 months.
Have you participated in a Fruit & Vegetable Coupon or Delivery Program within the last 6 months?
Are you interested in learning more about Produce Perks eligibility?
Community Interest
What are you interested in?
Mailing List
Would you like to join our mailing list for updates, events, and Produce Perks announcements?
Would you like to receive updates about the September 19 Community Market Event?
Agreement
Please check all statements to confirm your understanding:
Should be Empty: