Healthy Foods, Healthy Families

Healthy Foods, Healthy Families

Participant Sign-up Sheet

Please complete with PARENT/GUARDIAN information.

1.  First & last name: ______

2.  Gender: ______

3.  Date of Birth: ______

4.  What are your children’s ages?______

5.  How many adults are in your household (counting yourself)?______

6.  Are you currently receiving WIC and/or SNAP benefits? ____ WIC ____ SNAP

7.  Have you participated in Healthy Foods, Healthy Families before?

_____ Yes _____ No _____ I don’t know

8.  What brought you to the farmer’s market today? (✔ all that apply)

______I heard about the Healthy Foods, Healthy Families Program and wanted to sign up

______I just came to check out the market and see what was here

______I shop regularly at the farmers market

______Other______

9.  How did you hear about Healthy Foods, Healthy Families? (✔ all that apply)

___Flier in community ___Flier in child’s backpack ___Just walking by

___Friend ___WIC office ___Was in program before ___Other: ______

10.  Why do you want to participate in Healthy Foods, Healthy Families? (✔ all that apply)

___ Concern about family’s health ___ Bonuses ___ Child’s weight

___ Parent’s weight ___ Nutritional Education ___ Other:______

11.  What race or ethnicity do you identify with? (✔ all that apply)

___ White/ Caucasian ___ Asian

___ Black or African American ___ Other: ______

___ Latino/a

12.  What is your preferred language? (✔ the best option)

____English ____Spanish ____Nepali Other: ______

13.  What kind of health insurance do you receive? (✔ the best option)

___Blue Cross/Blue Shield ___United Health Care

___Neighborhood Health Plan ___Uninsured ___Other: ______

14.  What is your zip code? ______

15.  What is your email address? ______

16.  Your phone number(s): (H) ______(Cell) ______

For the following questions, please CIRCLE the best response.

17.  How much of your family’s weekly WIC/SNAP budget is spent on fruits and vegetables?

a.  A lot (Above 50%)

b.  Some (Between 26-50%)

c.  Very little (Between 10-25%)

d.  None

18.  How many times do you consume soda on a daily basis?

a.  0 b. 1 c. 2 d. 3+

19.  On an average day, how manytimes do you have a vegetableto eat?

a.  0 b. 1 c. 2 d. 3 e. 4 f. 5+

20.  On an average day, how many times do you have afruitto eat?

a.  0 b. 1 c. 2 d. 3 e. 4 f. 5+

21.  How many of the fruits and vegetables at the farmers market do you feel confident to cook and eat at home?

a.  A lot (Above 50%)

b.  Some (Between 26-50%)

c.  Very little (Between 10-25%)

d.  None