Homemade Nourish Membership Sign-Up Form

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Homemade Nourish Membership Sign-Up Form

Please provide all the information requested below to complete the sign-up process to become a Homemade Nourish member.

Name *

Email Address *

Mailing Address *

Phone Number *

Which chronic medical conditions do you have? *

High Blood Pressure

Diabetes

High Cholesterol

Heart Disease (history of heart attack, stent placement, bypass surgery, Congestive heart failure (CHF)

Congestive Heart Failure (CHF)

Chronic Kidney disease (CKD)

Other:

Required

Name of medical provider/s who is/are treating your chronic medical condition listed above

Which of the following stores do you shop at?

Fred Meyer

Roth’s Fresh Markets

Safeway

Winco

Lifesource

Natural Grocers

Trader Joe’s

Whole Foods

Grocery Outlet

Other:

Are you eligible for federal food assistance programs such as Supplemental Nutrition Assistance Program (SNAP) or Women, Infants and Children (WIC)

Yes

Don’t know

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In the past 3 years, have you needed assistance from hunger-relief charities or community organizations (local food bank, food pantry, soup kitchen, shelters)?

Yes

Clear selection

Do you have adequate information about the nutritional changes that you need to make to help better manage your medical condition?

Yes

Clear selection

Do you have adequate access to healthy food choices in your neighbourhood to help you improve your health?

Yes

Clear selection

Would you like Homemade Nourish to send you information about nutritional guidelines and advice for your medical condition, as well as discounts and other money-saving incentives in your neighbourhood?

Yes

Clear selection

Any other details that you would like to share?

Submit

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