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Franklinton Gardens 2017 CSA Commitment Form (June-October Season)
Hello! We are excited that you are interested in signing up for the Franklinton Gardens Community Supported Agriculture (CSA) program. This year's program will run from June 1st to October 19th and will offer delivery of the weekly produce to your home. We are asking you to complete this form as a sign of your commitment to participating. If we have more than 40 people sign-up, we will maintain a waiting list.

We will be following-up between mid-April/early May to finalize details. Since our CSA program is being supported through a grant, we will be requiring some additional information, which will be kept confidentially, to assist with grant reports. This includes a pre-season and post-season survey and a pre-season and post-season meeting. We will offer several times/days to attend and are asking information on this form about how to best accommodate all of our participants.

Your answers are not being used in any way related to eligibility, but to track program participant demographics for our funding source. No personal information will be connected to your names and all answers are confidential.

Contact Katie Brokenshire at katie.brokenshire@franklintongardens.org for CSA-related questions or Michelle Kaiser at kaiser.267@osu.edu for questions about the grants and surveys. We are so happy that you have decided to join us this coming season!!

We have filled all our spots for Full-Price Shares. However, we will put you on a waiting list for 2017 shares and the contact list for next year if you complete the following form. There are a limited number of spots left for half-price shares as well! (either through EBT/SNAP or Franklinton Gardens subsidies) We will update this when those are filled and we create a waiting list for those as well.
Please write the first and last name of the primary contact person in your household. This person should be 18 years of age or older.
Your answer
Please write the age of the primary contact person in the household at the time of this survey.
Your answer
Please write your address where the CSA would be delivered.
Your answer
Email address for primary contact-If you do not have an email or do not use the email, just write NA.
Your answer
Phone number for primary contact-If you do not have a phone number, just write NA.
Your answer
If we need to reach you, which method do you prefer?
Please indicate whether your household has ever participated in the Franklinton Gardens Summer CSA (weekly produce delivery program).
Please indicate whether your household has ever participated in the Franklinton Gardens Winter CSA (weekly produce delivery program).
How many adults (18 or older), including yourself, generally live in your household?
If you answered "More than 5" adults in the previous question, please write in the number of adults (18 or older), including yourself, who generally live in your household. If not applicable, write NA.
Your answer
How many children (0-17 years old) generally live in your household?
If you answered "More than 8" children in the previous question, please write in the number of adults (0-17), including yourself, who generally live in your household. If not applicable, write NA.
Your answer
How many people (including yourself) in your household identify as female? If not applicable, write NA.
Your answer
How many people (including yourself) in your household identify as male? If not applicable, write NA.
Your answer
How many people (including yourself) in your household identify as transgender or identify in some other way besides female or male? If not applicable, write NA.
Your answer
Please indicate whether you or any person in your household is of Hispanic or Latino descent.
If you answered yes to the question above, how many people in your household identify as being of Hispanic/Latino descent? If not applicable, write NA.
Your answer
The US Census uses several categories of race. How would you best describe the race of the primary contact in the household?
If others in your household identify with a different race (from the categories above) of the primary contact in the household, please describe the race of others who are regularly living in the household. [For example, if the primary contact identifies as American Indian, but three other household members identify as Black, White, and Two or More Races, you would write 1-Black, 1-White, 1-Two or More Races. Please use the US Census categories from the above question.] If Not Applicable, write NA.
Your answer
Please indicate if the number of people in the household who are 60 years of age or older. If not applicable, write NA.
Your answer
Please write the ages of the individuals who are 60 years of age or older, to the best of your knowledge, at the time of the survey. If not applicable, write NA.
Your answer
Please indicate if the number of people in the household who are 5 years of age or younger. If not applicable, write NA.
Your answer
Please write the ages of the individuals who are 5 years of age or younger, to the best of your knowledge, at the time of the survey. If not applicable, write NA.
Your answer
Please indicate whether any person regularly living in the household identifies as a military Veteran.
Please indicate how many people regularly living in the household identify as a military Veteran. If Not Applicable, write NA.
Your answer
Please indicate whether any people regularly living in the household were born outside of the US?
Please write the number of people regularly living in the household who were born outside of the US and what each individual identifies as the country of origin. If not applicable, write NA. If you are unsure or do not want to answer, please write that here.
Your answer
Please indicate whether anyone in your household has participated in any of the following programs in the last year. Check all that apply.
Required
Please indicate whether anyone in your household receives income from any of the following sources in the last year. Check all that apply.
Required
Please indicate your household's estimated total monthly income (from all sources in the previous section). Again, this is not used in determining any eligibility.
Your answer
If you participate in SNAP/EBT/Food Stamps, please indicate how much your household receives from SNAP/EBT/Food Stamps during most months. If you do not participate in this program, write Not Applicable or NA.
Your answer
If you participate in WIC, please indicate how much your household receives from WIC during most months. If you do not participate in this program, write Not Applicable or NA.
Your answer
Please write the names of the stores where you shop regularly. If it is a chain store, please try to describe the location as best you can.
Your answer
Do you or anyone in your household have a fairly reliable car?
If you do not have a car, please indicate the main transportation methods to get to appointments or food stores. Check all that apply.
Required
How did you hear about Franklinton Gardens/CSA?
Your answer
Please indicate whether you have participated in any of the other Franklinton Gardens Programs in the past year. Check all that apply.
Required
Please indicate whether you are interested in a full-price share ($20/week) or a half-price share ($10/week). The half-price shares still include the same amount of produce, but are subsidized through grants, donations, and Veggie SNAPs.
Please indicate whether you would be interested in any of the following opportunities prioritized for CSA members. Check all that apply.
Required
Would anyone in your household identify as a person of Appalachian heritage?
Please let us know why you want to participate in the CSA Program or any other information that would be helpful! Thanks so much for your time completing this form.
Your answer
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