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FARM Rx 2024 Waitlist Form
Quick survey to add potential FARM Rx participants to meet our goal of 100 families participating in FARM Rx 2024
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* Indicates required question
What is your household size?
*
Your answer
First and last name
*
Your answer
Phone number
*
Your answer
Email
*
Your answer
"Within the past 12 months, we worried whether our food would run out before we got money to buy more." Was this often true, sometimes true, or never true for you and/or your household?
*
Often True
Sometime true
Never True
"Within the past 12 months, the food we bought just didn’t last and we didn’t have the money to get more." Was this often true, sometimes true, or never true for you and/or your household?
*
Often True
Sometimes True
Never True
How did you hear about this program?
*
St Mary's
Piedmont
Mercy Clinic
Veteran Affair's Office (VA)
Athens Farmers Market
Friend Referral
Public Library
Other:
What county do you live in?
*
Your answer
Do you suffer from one of the following illnesses?
*
Diabetes
Heart disease
Obesity
Hypertension
None of the above
Other:
Required
Do you have a kitchen where you can store and cook food?
*
Yes
No
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