Regenerative Roots CSA Membership Application
Thank you for your interest in becoming members of our farm for the 2017 season! We welcome you as a friend of sustainable farming and delicious food. CSA is all about community - it's a model where customers choose to support a specific farm for a full growing season in exchange for a weekly box of produce (~a grocery bag worth; enough for 2-4 people). Members enjoy extremely fresh produce, eating healthy, and receive newsletters with farm news, recipes, and invitations to events on the farm throughout the season. We offer two different size shares (Family & Personal).

Please take a moment to answer the following questions about yourself and state your preferences for your membership size and pick-up location. We do not collect payment(s) online, so please send checks ASAP to secure your membership, as we have limited spots available and sell out every year!

Some members may choose to share their membership with another individual or family. If this is the case, please make sure to include all their information at the bottom of this form!! Also at the bottom of the form is a 'Submit button' - make sure to click it when you're finished.

Discounted CSA shares are available to low-income families through the partner shares program. Also, several local HMO providers offer rebates for CSA shares up to $200. See the Partner Shares Program and Health Insurance Rebates pages on our website for more details (under "CSA Membership").

Make sure you read the Member Handbook as well:

To Your Health! ---Anne and Dennis, Regenerative Roots, LLC

General Information
Member Name *
Your answer
Primary E-mail Address(es) *
Your answer
Primary Mailing Address *
Your answer
Primary Phone Number(s) *
Your answer
How did you hear about us? (Check all that apply).
Membership Preferences
What type of share are you interested in receiving? *
If you're looking for variety, Family shares will get a wider variety of produce overall. Family Shares typically have everything in the personal share plus several additional items.
Would you like a copy of the Farm Fresh and Fast cookbook?
This stellar cookbook is produced by the FairShare CSA Coalition with you, the CSA member, in mind! Tips on making the most of fresh, seasonal and local produce abound, and you get $5 off the shelf price! We will have cookbooks available for pickup during the first CSA week with your share.
Pick-Up Site Preference
Where would you like to pick up your CSA share? (All pick-ups are Thursday, 3-7pm) *
The farm is about 4 miles north of Fort Atkinson and 4 miles southwest of Jefferson.
Are you interested in hosting a pickup site for the CSA?
Site hosts may receive a discount on their share and are responsible for maintaining a clean and orderly site, contacting members who have not picked up their share on pick-up days, and after a day are entitled to any shares not picked up. Hosts are not required to be around during pick-up hours, but it can be a great opportunity to get to know your fellow CSA members! We will consider adding a new pickup site if it has at least 5 members.
Payment Preference
How would you like to make your payment(s)? *
Please make checks payable to "Regenerative Roots" and mail them after completing this form to: Regenerative Roots, W6635 Kiesling Rd, Jefferson, WI 53549. YOUR MEMBERSHIP WILL NOT BE COMPLETE UNTIL WE RECEIVE YOUR PAYMENT(S). Please send all checks at once, including post-dated ones.
Member Agreements
As a CSA Member, you are truly a shareholder in your local food economy: you connect with your community, support local farmers, and voice your right to have good, healthy food. Please read the statement below: *
Our primary goal as CSA farmers is to provide you with the highest quality produce we can grow. We will try our best to make your share as valuable to you as your membership is to us! Many circumstances are beyond our control, and in the event of a partial or complete crop failure from weather or pests, we may fill your share with other crops grown on the farm that are ready for harvest at that time or buy in produce from other organic farms. This may not be a feasible option for all crops because of cost or widespread failure. Weekly boxes may vary somewhat in size, but should average out to being at or above market value.
Please read the following regarding your responsibilities as a member: *
• CSA membership is a season long commitment. If you can’t complete the season as members, for whatever reason, you are welcome to reassign your share to another household, but in general we don’t issue refunds for shares. • You are responsible for picking up your share. If you are unable to pick up your share on delivery day, you must make alternate arrangements for your share ahead of time. You can ask someone else to pick up for you, you can ask the farm not to make a box for you that week. If you forget to pick up your share on delivery day, it will be donated to a food pantry or neighborhood family. • Keep a copy of your site host's contact info. • Read the newsletters and emails from the farm. You'll find important announcements, recipes, and news from the farm. • Bring a bag to unpack your box into; you may not take the plastic box home.
Please read the Member Handbook (link at the top of the page) *
Donate to FairShare and Support Fresh Food for All!
For over 20 years, FairShare CSA Coalition has been a nationally recognized leader and innovator in the local food movement. From coordinating the 1st Annual CSA Open House in 1993, developing the Health Insurance Rebate Program in 2006, to becoming authorized to accept SNAP benefits (food stamps) for CSA purchases in 2010, they have worked tirelessly to build a healthy, accessible good food community. Your donations help FairShare provide support to CSA farmers, educate thousands of consumers about the benefits of fresh local foods, and operate the Partner Shares Program to make CSA affordable for hundreds of low-income households. Please visit to show your appreciation.
Second Household
Are you sharing your CSA with another individual or family? If so, please complete the following four questions for the Second Household. [Please be aware that members who are splitting a share are responsible for coordinating this on their own and picking up an entire share. Regenerative Roots will not allow partial shares to sit at the pick-up site, as it inconveniences other members. Thanks!]
Second Household Member Name(s)
Your answer
Second Household E-mail Address(es)
[This will be our main method of getting in touch with the folks who will be sharing your CSA share]
Your answer
Second Household Mailing Address
Your answer
Second Household Phone Number(s)
Please list both home and mobile numbers, if applicable
Your answer
Never submit passwords through Google Forms.
This form was created inside of Regenerative Roots, LLC. Report Abuse - Terms of Service