Franklinton Farms Summer 2019 CSA Sign-Up Commitment Form
Hello!  We are excited that you are interested in signing up for the Franklinton Farms Community Supported Agriculture (CSA) weekly Produce Basket Program. This year's program will run for 20 weeks from May 16 through September 26 for 55 members who live or work in Franklinton.  We are asking you to complete this form as a sign of your commitment to participating.  Information about your payment ($7/$10/$14/$20/week), payment method (check, card, SNAP/EBT, Produce Perks, cash), and payment plan is in the survey.

Each household must complete this commitment form every season. We appreciate your time and commitment to Franklinton Farms. We will be following-up in the next few weeks to finalize details, including details about distribution days and payment procedures.  

Your answers are not being used in any way related to eligibility, but to track program participant demographics for our funding sources.  No personal information will be connected to your names and all answers are confidential.

Since our CSA program is being supported through a grant, we will be asking you to complete some additional information through surveys or interviews, which will be kept confidentially, to assist with grant reports.  A mid-season, post-season survey, and additional meetings or focus groups will be requested, but not required for your participation in the CSA program.  They are also part of an Ohio State research project. You will have a chance to consent to participate in the OSU research project.  

Contact Franklinton Farms Farm Manager, Michelle Nowak at michelle.nowak@franklintonfarms.org for CSA-related questions or Michelle Kaiser at kaiser.267@osu.edu for questions about the grants, surveys, or any problems with the forms.  Please note that you will need to answer all questions that are required before submitting.  Google Forms will tell you if you are missing anything.  

We are so happy that you are considering joining us this coming season!!  


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An example of our $20-value CSA: Please note that contents vary throughout the season.
Please write the first and last name of the primary contact person in your household. This person should be 18 years of age or older. *
Please write the age of the primary contact person in the household at the time of this survey. *
Please write your home/billing address if it is different than where the CSA is delivered.
Email address for primary contact-If you do not have an email or do not use the email, just write NA. *
Phone number for primary contact-If you do not have a phone number, please let us know how we can reach you if email or in-person communication is not working (e.g., an alternative phone number). *
If we need to reach you, which method do you prefer? *
Please indicate whether your household has ever participated in the Franklinton Farms (Gardens) Summer CSA (weekly Produce Basket delivery program). *
Please indicate whether your household has ever participated in the Franklinton Farms (Gardens) Winter CSA (weekly Produce Basket delivery program). *
Please indicate how many times your household has participated in a Franklinton Farms (Gardens) CSA Program (Winter or Summer). If you have not participated, write 0. If you are unsure, please provide your best estimate. *
How many people generally live in your household *
How many children (0-17 years old) generally live in your household? *
How many people (including yourself) in your household identify as female? If not applicable, write NA. *
How many people (including yourself) in your household identify as male? If not applicable, write NA. *
How many people (including yourself) in your household identify as transgender or identify in some other way besides female or male? If not applicable, write NA. *
Please indicate whether you or any person in your household is of Hispanic or Latino descent. *
If you answered yes to the question above, how many people in your household identify as being of Hispanic/Latino descent? If not applicable, write NA. *
The US Census uses several categories of race.  How would you best describe the race of the primary contact in the household?   *
If others in your household identify with a different race (from the categories above) of the primary contact in the household, please describe the race of others who are regularly living in the household.  Check all that apply. *
Required
Please indicate if the number of people in the household who are 60 years of age or older.  If not applicable, write NA. *
Please indicate if the number of people in the household who are 5 years of age or younger.  If not applicable, write NA. *
Please indicate whether any person regularly living in the household identifies as a military Veteran. *
Please indicate how many people regularly living in the household identify as a military Veteran.  If Not Applicable, write NA. *
Please indicate whether any people regularly living in the household were born outside of the US? *
Please write the number of people regularly living in the household who were born outside of the US and what each individual identifies as the country of origin.  If not applicable, write NA. If you are unsure or do not want to answer, please write that here. *
What language(s) is/are spoken in your home? *
Would anyone in your household identify as a person of Appalachian heritage? *
Please indicate whether anyone in your household has participated in any of the following programs in the last year.  Check all that apply. *
Required
Please indicate whether anyone in your household receives income from any of the following sources in the last year.  Check all that apply. *
Required
Please choose the range of your household's estimated total annual income (from all sources in the previous section). Again, this is not used in determining any eligibility; we aggregate member data for our grant funder. *
If you participate in SNAP/EBT/Food Stamps, please indicate how much your household receives from SNAP/EBT/Food Stamps during most months. If you do not participate in this program, write Not Applicable or NA. *
If you participate in WIC, please indicate how much your household receives from WIC during most months. If you do not participate in this program, write Not Applicable or NA. *
Do you or anyone in your household have a fairly reliable car? *
If you do not have a car, please indicate the main transportation methods to get to appointments or food stores.  Check all that apply. *
Required
What's the highest level of education you  have completed?  This is for reporting purposes and will be aggregated.   *
How did you hear about Franklinton Farms/CSA?
Please let us know why you want to participate in the CSA Program or what you hope to get out of the CSA Program, along with any other information that would be helpful!   *
Please indicate whether you have participated in any of the other Franklinton FarmsPrograms in the past year. Check all that apply. *
Required
Please indicate whether you are interested in a full-size full-price share ($20/week), a full-size reduced-price share ($10/week), a small full-price share ($14/week), or a small reduced-price share ($7/week).  The reduced-price shares still include the same amount of produce, but are subsidized through grants and donations. The small-sized shares are new this year for households who want a smaller amount of produce. *
Please indicate how you would like to pay for your CSA share. *
Required
Please indicate if you are interested in learning more about using your SNAP/EBT along with Produce Perks to reduce the price of your share even more. *
Please indicate what payment plan you can most likely commit to. *
Please indicate whether you would be interested in any of the following opportunities prioritized for CSA members. Check all that apply. *
Required
We are always looking for additional ways to support our programming (e.g., low-cost CSA shares for Franklinton residents, education). Please indicate if you would be interested in donating this year to help pay it forward.  You are not committing to this, but we will contact you sometime in the future. *
If you are interested and able to pay it forward, how much might you be able to give this year?
Clear selection
How frequently do you eat fruits and vegetables right now? (USDA question) *
How easy is it for your get fresh fruits and vegetables on a regular basis? (USDA) *
If it is hard to get fresh fruits and vegetables on a regular basis, why is that so? If it is not, just write NA. (USDA) *
We are considering offering local pick-ups of CSA bags, in addition to delivery, this summer in Franklinton. CSAs are packed and shared on Thursdays. Please indicate your preferred choice. *
Please write your address where the CSA would be delivered. If you would like to pick-up your CSA bag, please write "pick-up" here and respond to the next question. *
If you are interested and able to pick up your share on Thursdays, please let us know which of the following places you would be willing to go to pick up your CSA.
We want to be sure we have a place to deliver your produce that will be safe, accessible, and preserve the best quality of your CSA.  Please let us know any special instructions concerning the delivery of your Produce Basket.
Please indicate if you would be interested in a work trade option for a reduced price for your CSA.  Work trade could include tasks like helping Franklinton Farms write the weekly CSA newsletter, assisting with produce distribution, or other opportunities that would require some level of commitment.   *
Would you be interested in adding flowers from a neighbor to your share for an additional cost of $10/week from a local grower? *
Would you be interested in participating in a Franklinton Farms composting program where 5 gallon buckets of your household food waste are picked up by Franklinton Farms when CSA shares are delivered or picked up at CSA pickup locations? Franklinton Farms would then compost this waste. *
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