Wild Willow Wellness Apothecary Become an Apothecary Member! - This form takes 5-10 minutes to fill out.

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If you are not available for local (Helena, Montana) pick up/delivery, please do not sign up to be a member! Questions, please call (406) 465-6214. If you decide you'd like more info before you sign up, please fill out my Info Sessions Form, and I will be in touch! I don't currently have any scheduled, but I will call you if you fill out the form.

Pricing for this 4 season cycle are is as follows: 1 Wellness Kit = $130; 2 Wellness Kits = $250; 3 Wellness Kits = $360; 4 Wellness Kits = $460. For each kit you get, the pricing goes down per kit by $5. There are 4 seasonal kits total in a year: Fall, Winter, Spring, and Summer. You can read through this form prior to filling it out so you can understand more. So excited you are considering opting into our wellness kits! Warmly, Jesse (your community herbalist)

Email *

First Name *

Last Name *

Phone Number *

Mailing Address *

Birthday (Just month and day) *

Part 1: What are the top 3 values are influencing your decision to become a member?

Please check your top 3 reasons for joining the apothecary.

Personal Health

Health of Family

Increasing local biodiversity

General environmental concerns (clean water, air, soil)

Supporting women owned businesses

Connecting with like-minded people

Supporting local businesses

Regenerative farming support/interest

More visibility of indigenous culture

Part 2: What values outside your top 3 are influencing your decision to become a member?

Personal Health

Health of Family

Increasing local biodiversity

General environmental concerns (clean water, air, soil)

Supporting women owned businesses

Connecting with like-minded people

Supporting local businesses

Regenerative farming support/interest

More visibility of indigenous culture

Please indicate the number of wellness kits you would like (you have the option to pay all at once up front or to pay monthly, which is divided by the month you are signing up through June). Here are the Seasonal Wellness Kit General Descriptions to review prior to selecting. *

4 kits ($460)

3 kits ($360)

2 kits ($250)

1 kit ($130)

Other:

Which Seasons(s) are you selecting?

Fall (Fall Equinox)

Winter (available Winter Solstice)

Spring (available Spring Equinox)

Summer (available Summer Solstice)

All 4 seasons

Other:

2 Reduced price massages are available per wellness kit. The price of a 90-minute massage is $169 instead of $186 and must be paid in full ahead of time or divided into your monthly payment on the cycle of this month, through June.

(Optional) How many reduced price massages would you like?

Generally apothecary members pick up their wellness kits, but if you need to have yours delivered, the cost is $22/delivery. Please select your options below.

(Optional) For which wellness kits would you like delivery?

Fall

Winter

Spring

Summer

No delivery needed

Other:

Estimated cost for any additional choices *

Total cost (Wellness kits, Optional Massage and/or Delivery) *

Will you pay in full or monthly? *

Pay in Full, and be on an annual auto deduction every July 15, through checking account or credit/debit card

Pay Monthly through June, and be on a continual monthly cycle, which renews each year on July 15 by checking account or credit/debit card

Other:

Please read and check off that you understand the following Wild Willow Wellness Apothecary Policies.

Read the Nature of CSA Relationship here

A check next to each policy notes that you have read, understood, and agree.

I have read Nature of CSA Relationship and agree to be a member shareholder of the Wild Willow Wellness Apothecary.

I understand that I am responsible for picking up my wellness kit(s) unless I indicated delivery, and that if I am unable to make the pick-up times offered, I will ask a person to pick up on my behalf at the pick-up times offered. I also understand that it is the policy of the apothecary to deliver the kits ($15) at a time of their choosing if for some reason my kit can’t be picked up, and that the delivery cost will be automatically deducted from my credit card or checking account if that happens.

I understand that once I’ve decided upon the number of kits/massages for my CSA cycle (July-June every year), and in the instance of moving away or a change in circumstances, I will not be able to cancel my membership/costs in the middle of a cycle unless agreed to by Wild Willow Wellness Apothecary. If not agreed to by the apothecary, I understand that I can donate my kits in this circumstance to a person of my choosing (who must pick up during the scheduled pick-up dates) or the apothecary will choose a recipient in need.

I understand that if I want to change the number of kits I receive to a greater or lesser # of kits during a 4-season cycle, this carries a $50 fee to cover the administrative time. I understand that If I want to change at the beginning of a new cycle, there is no fee. The new cycle and time to change is between June 15 and July 15 every year.

I understand that my credit card or account checking and routing number will be kept on file for auto deduction, and that this automatically renews each year. I understand that I will receive notice of the auto renewal 2 weeks ahead of the renewal so that I have time to make a decision to change or cancel the next annual seasonal wellness kit cycle.

Required

In this final section, please fill out your bank checking account info or credit/debit card information.

For E-check: Enter your checking account number

For E-check: Enter your bank's routing number

Section 4: Credit or Debit Card Info

Name on Credit Card

Credit Card Number

Billing Address

Expiration Date

Security Code

Thank you for supporting Wild Willow Wellness Apothecary, a community that values local products that benefit our bodies and our earth by growing and providing products that are free of herbicides/pesticides, and contain pure and simple organic plant based ingredients. You are making an investment that is in line with your core values, and that matters. As your farmer and provider of these products, I am grateful to you for this opportunity to serve you, family, and our community.

A copy of your responses will be emailed to the address you provided.

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