Farmers' Market Coupon Program - Application Form Farmers' Market Coupon Program - Application Form Name * Name First First Last Last What is your Gender? (for statistical purposes only) * Man Woman Non-binary/non-conforming Transgender Two Spirit OtherOther What best describes your status with the Central Okanagan Food Bank? * I am a registered client and I have received services in the last 6 months I am a registered client but I have NOT received services in the last 6 months I am not a registered client but I plan to register I am not a registered client and I do NOT plan to register Email * Phone * Including yourself, how many people in your household are pregnant? * Including yourself, how many people in your household are over 55 years of age? * Including yourself, how many people in your household are under 19 years of age? * Including yourself, how many total people are in your household? * Is anyone in your household Indigenous? * Yes No Prefer Not to Say If Yes, please select: First Nations Métis Inuit Prefer not to Say Don't Know What would you like to learn more about as part of this program? Check all that apply: Skill & Experience in Preparing Food Food preparation using utensils and appliances Following instructions in recipes Improvising with ingredients Knowing About Nutritious Food Information about food and nutrition How to read food labels Where food comes from Cooking food and storing it safely How shopping at a farmers' market impacts your community Organization, Skills, & Experience Preserving foods such as canning, freezing, or dehydrating Buying healthy food on a budget Buying and storing foods Planning healthy meals Personal & Social Factors More confidence buying healthy foods Connecting to other people in my community Feeling healthy and well Other: Authorization I agree to be a part of the BC Farmers' Market Nutrition Coupon Program. I understand the program provides fresh, local food for those who face financial challenges. I understand that these coupons are for my family's or my own personal use only. These coupons will only be used by me/my family only. Any unwanted tickets will be returned to the Central Okanagan Food Bank. * I agree If you are human, leave this field blank. Submit
