Farm-Based Wellness Program Application
Are you or a member of your family at risk for or diagnosed with high blood pressure, high cholesterol, pre-diabetes, diabetes, or heart disease? Join our Farm-Based Wellness Program and start your journey towards a healthier lifestyle!

We are currently accepting applications for our 2023 Farm-Based Wellness Program. All interested participants are encouraged to apply to our program. New Haven residents that are able to commit to the summer program, with a diet-related illness or symptom are welcome to apply.

For assistance completing this application, please call/email Peter at (203) 516-7270 or peter@gathernewhaven.org

We encourage a whole foods plant-based diet for health promoting reasons related to both individual health and to reduce the impact our food choices has on our environment.

Vaccination policy - It is not required to be vaccinated*. However, if you do not feel well, we encourage you stay home until your symptoms are gone.

For more information about our program please visit us at
https://gathernewhaven.org/our-programs/farm-based-wellness-program
Sign in to Google to save your progress. Learn more
Have you (or your child) been diagnosed (either by a medical provider or self-diagnosed) with a diet-related illness or symptom? *
Required
An important part of the program is to record our progress by using a journal to log our food and physical activity. Is this something you would be willing to maintain throughout the duration of the program? *
Whole food plant-based philosophy
We encourage participants to eat more whole food plant-based meals, and plan to demonstrate whole food plant-based recipes during the program.
Applicant Information
Applicant's First Name *
Applicant's Last Name *
Applicant's Date of Birth (MM/DD/YY) *
MM
/
DD
/
YYYY
What are your general goals and/or expectations for participating in the program? (Adults only)
Why is this your goal/expectation?
If applying on someone else's behalf, First name of contact (or Guardian)
If applying on someone else's behalf, Last name of contact (or Guardian)
The Farm-Based Wellness Program meets weekly on Tuesday (Spanish) and Thursday (English) evenings from 5:30 - 7:30 pm in the Fair Haven neighborhood, Ferry st. Farm (613 Ferry st., New Haven). Which day are you applying for?
 *
Contact Information
What is your mailing address (Street, City, State, Zip Code)?
*
Phone Number *
Do you give Gather New Haven permission to send text reminders and updates about our program to your phone? *
Email Address
*
Emergency Contact Information
Children attending with their parents can have their parents as their emergency contacts, but an alternative emergency contact should be encouraged. (Enter "Parents" for both responses if the parents decide to not add an additional contact).
Please provide us with a name for an emergency contact in case of an emergency. *
Please provide us with a number for your emergency contact in case of an emergency. *
Health Care Information
Gather New Haven works closely with health care providers to receive referrals to our Farm-Based Wellness Program. The following questions are related to your health care.
How did you hear about our Farm-Based Wellness Program? *
Required
Were you referred to our program by your health care provider? *
Where do you go for health care services? *
Program Logistics
Our Farm-Based Wellness Program is a year-round program. We meet outdoors on the farm once a week for 16 weeks in the summer between the mid May to the end of August. During the winter months we meet indoors once a month for our Winter Monthly Meetings.
We plan to offer a Youth Program for the children (between the ages of 8-17) of our adult participants. When you attend class, do you plan on bringing children or teens to our Youth Program? If so, how many and how old are they?
Do you (or child participant) have any allergies? If so, what are they? *
Reliable transportation
For participants that do not have reliable transportation, document there answer and let them know that we will be able to provide transportation to and from program sites within New Haven.
Do you have reliable transportation to attend the weekday (Tuesday/Thursday) program? *
Join us on Facebook and/ or Instagram!
If you haven't already, please feel free to join us on Facebook by searching, "Farm-based wellness program" or "Programa de bienestar basado en la granja" and ask to join the group. We plan to share lifestyle related advise and update the page with information related to the FBWP events. Instagram @gathernewhaven
We will reach out in May 2023 to confirm your application status, thank you!
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Gather New Haven. Report Abuse
Google Forms