Community Harvest Program Registration
Thank you for your interest in Community Harvest! Anyone is welcome to sign up. Please complete this form if you would like healthy, prepared meals and/or a CSA (Community Supported Agriculture) providing fresh local produce and pantry staples weekly.

Community Harvest runs in 8 week sessions. The 2nd Spring Session runs from the week of April 19th to the week of June 12th. If you would like to join earlier, we can add you to the waitlist for the session that is currently running.

Questions? Contact Julia at or 402-690-0888 (text or call)
Primary Contact First Name *
Primary Contact Last Name *
Primary Contact Age *
Date of Birth *
Other Household Contact Name(s)
Please list any other people in the household who may be contacted. Separate by comma. (i.e. John, Mary, Joe)
Street Address *
City *
State *
Provide two letter state code. (i.e. NE)
Zip Code *
Phone number
In this format: XXX-XXX-XXXX
Preferred Method of Contact
Clear selection
Number of people receiving food *
Of those receiving food, how many are under 18 years old? *
Of those receiving food, how many are over 60 years old? *
Were you referred by a person or organization? If so, who? *
What type of food do you need? *
How many meals would you like per week?
Meals are plant based using local ingredients and packaged in individual microwave and oven-safe trays. Perfect for lunch or dinner! Two types of meals per week
How many CSA boxes would you like per week?
CSA boxes include raw produce sourced from local farmers. Six to seven different items in each box. One box will make at least two meals for a family of four.
Can we use your story in our marketing, communications, and fundraising materials?
Clear selection
Pick Up Or Delivery *
Delivery reserved for those who are homebound, quarantined, without a car, unable to drive, or other circumstances that prevent picking up. Food must be picked up each week & communicated to Julia when you cannot make it. You may send someone else to pick up your food.
Never submit passwords through Google Forms.
This form was created inside of No More Empty Pots. Report Abuse