From the Ground Up Enrollment Form
Disclaimer: All information recorded will be kept confidential, unless you are in need of additional referrals to housing assistance or mental, physical, or dental health services.
Email address *
First Name *
Your answer
Last Name *
Your answer
Date *
MM
/
DD
/
YYYY
Primary Legal Guardian *
Required
Name of Person Assisting with Intake
Your answer
Phone Number *
Your answer
Gender Identification *
Your answer
Age *
Your answer
County of Residence *
Your answer
Referred by: (Name of Agency or Church that you are filling this form with) *
Your answer
Are you currently housed (Living in apartment, home, or transitional housing) and do you have the means to properly store vegetables and meat? *
If you have answered yes, please skip the next question.
If you answered no, would you like to be connected to housing assistance services?
Do you have physical limitations (including disability, chronic pain, or heat exhaustion) that would prevent you from completing 3 hours of strenuous physical activity? *
If you have a reproductive system, would you like to be connected to FREE birthcontrol services? *
Do you have reliable transportation? *
If you have answered no, you can sign-up for free transportation via https://www.ethra.org/programs/41/ride-to-work/. Please contact us if you would like help with this process.
Employment Status *
Required
Do you currently access any sort of nutritional assistance programs? *
If you have answered no, please skip the next question.
Required
If you answered yes, which programs do you get assistance from?
Are you a U.S. Veteran? *
How many people currently live in your household? *
Your answer
Do you have children under the age of 18 in your household? *
If no, please skip the next question.
How many children, under the age of 18, live in your household?
Your answer
By digitally initialing this document, you are stating your interest in participating in Century Harvest Farms Foundation’s (CHFF) From the Ground Up Programming. You will be contacted by a CHFF representative within the business day, to verify information, transportation, and ensure that you have been connected to any additional services that you may be in need of. *
Please put your initials below.
Your answer
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