FYN Voucher Intake Form

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With charitable donations and community partner funding, Prescott Farmers Market may provide Feed Your Neighbors (FYN) vouchers to be used towards purchasing food staples of vegetables, fruit, nuts, herbs, eggs, bread, milk and meat from our vendors.

There is currently a waiting list to be accepted into the FYN voucher program.

Please complete this intake form to be added to the waiting list and to be contacted for additional assistance while the waiting list is in place.

Email *

First & Last name
*

First & Last names of all household members who may pick up vouchers.
*

Phone number where you can be reached for program check-in.
*

How many adults are currently living in your household? *

How many minors are currently living in your household? Please list the ages.
*

Are there other food assistance programs your household currently utilizes? (select all that apply) *

SNAP

WIC

CSFP

Food banks/pantries

Free and reduced school lunch program

None

Other:

Required

Are there additional food assistance programs that you would like information on regarding their resources? (select all that apply) *

SNAP

WIC

CSFP

Food banks/pantries

Free and reduced school lunch program

None

Other:

Required

How long do you anticipate needing FYN assistance to buy veggies, fruit and pantry staples? *

How did you hear about the FYN program? *

What's your zip code? *

Please carefully read the terms of agreement below and select boxes for each term with which you agree.
*

I understand that FYN vouchers are valid only for the purchase of staple food items- vegetables, fruit, herbs, seeds, nuts, eggs, meat, milk and bread. FYN vouchers may not be used for ready-to-eat food or drinks, crafts, personal care products or merchandise.

I understand that FYN vouchers may not be transferred outside of my household or sold to others.

I will contact the FYN coordinator by emailing marie@prescottfarmersmarket.org or TEXT 928-458-8425 should I have a change in need of food assistance and/or to cancel my participation in the program.

I understand any violation of these terms will result in removal from the FYN program.

I do NOT agree to these terms.

Required

Thank you for completing this form. PLEASE KEEP A COPY FOR YOUR RECORDS. Contact marie@prescottfarmersmarket.org or TEXT 928-458-8425 for questions or changes in your need of food assistance.

A copy of your responses will be emailed to the address you provided.

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