FOODiversity Registration – Free-From Market

Name*

First Last

Email*

Shipping Address*

Street Address City State ZIP Code

Phone*

What is your relationship to food allergies / sensitivities?*

Select all that apply

I have a food allergy and/or Celiac disease

I’m the parent/guardian of at least 1 child with food allergy and/or Celiac disease, 0 to 12 years old

I’m the parent/guardian of at least 1 child with food allergy and/or Celiac disease, 13 to 17 years old

I’m the parent of at least 1 adult child with food allergy and/or Celiac disease, 18 years or older

I have a spouse or partner with food allergy and/or Celiac disease

I have no relationship to food allergy or Celiac disease

Other

Other*

How many people in your household have dietary restrictions (e.g., food allergy)?*

5 or more

Client 1 Information

The person eating the groceries. If you are registering for yourself, you are Client #1.

Name*

First Name Last Name

Birthdate*

Gender*

Is the client of Hispanic, Latino, or of Spanish origin?*

Yes

Prefer not to answer

How would the client describe him/herself?*

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Other

Which food allergies does the client have?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almond, cashew, hazelnut)

Wheat

None

Other

Does the individual have any existing health conditions?*

Select all that apply

None

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Eosinophilic Esophagitis

Gastrointestinal Disease

Heart Disease

IBD (Inflammatory Bowel Disease)

Kidney Disease

Sickle Cell Disease

Other

List other allergies*

List other health conditions*

How would you rate the overall health of the client?*

1 (Poor health)

5 (Excellent health)

Client 2 Information

Name*

First Name Last Name

Birthdate*

Gender*

Is the client of Hispanic, Latino, or of Spanish origin?*

Yes

Prefer not to answer

How would the client describe him/herself?*

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Other

Which food allergies does the client have?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almond, cashew, hazelnut)

Wheat

None

Other

Does the individual have any existing health conditions?*

Select all that apply

None

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Eosinophilic Esophagitis

Gastrointestinal Disease

Heart Disease

IBD (Inflammatory Bowel Disease)

Kidney Disease

Sickle Cell Disease

Other

List other allergies*

List other health conditions*

How would you rate the overall health of client?*

1 (Poor health)

5 (Excellent health)

Client 3 Information

Name*

First Name Last Name

Birthdate*

Gender*

Is the client of Hispanic, Latino, or of Spanish origin?*

Yes

Prefer not to answer

How would the client describe him/herself?*

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Other

Which food allergies does the client have?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almond, cashew, hazelnut)

Wheat

None

Other

Does the individual have any existing health conditions?*

Select all that apply

None

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Eosinophilic Esophagitis

Gastrointestinal Disease

Heart Disease

IBD (Inflammatory Bowel Disease)

Kidney Disease

Sickle Cell Disease

Other

List other allergies*

List other health conditions*

How would you rate the overall health of the client?*

1 (Poor health)

5 (Excellent health)

Client 4 Information

Name*

First Name Last Name

Birthdate*

Gender*

Is the client of Hispanic, Latino, or of Spanish origin?*

Select all that apply

Yes

Prefer not to answer

How would the client describe him/herself?*

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Other

Which food allergies does the Client have?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almond, cashew, hazelnut)

Wheat

None

Other

Does the individual have any existing health conditions?*

Select all that apply

None

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Eosinophilic Esophagitis

Gastrointestinal Disease

Heart Disease

IBD (Inflammatory Bowel Disease)

Kidney Disease

Sickle Cell Disease

Other

List other allergies*

List other health conditions*

How would you rate the overall health of the client?*

1 (Poor health)

5 (Excellent health)

Client 5 Information

Name*

First Name Last Name

Birthdate*

Gender*

Is the client of Hispanic, Latino, or of Spanish origin?*

Yes

Prefer not to answer

How would the client describe him/herself?*

Select all that apply

American Indian or Alaska Native

Asian

Black or African American

Middle Eastern or North African

Native Hawaiian or Pacific Islander

White

Other

Which food allergies does the client have?*

Select all that apply

Egg

Fish

Milk / Dairy

Peanut

Sesame

Shellfish (e.g., shrimp, crab, lobster)

Soy

Tree Nut (e.g., almond, cashew, hazelnut)

Wheat

None

Other

Does the individual have any existing health conditions?*

Select all that apply

None

Cancer

Crohn’s Disease

Celiac Disease

Diabetes - Type 1

Diabetes - Type 2

Eosinophilic Esophagitis

Gastrointestinal Disease

Heart Disease

IBD (Inflammatory Bowel Disease)

Kidney Disease

Sickle Cell Disease

Other

List other allergies*

List other health conditions*

How would you rate the overall health of the client?*

1 (Poor health)

5 (Excellent health)

Your Household

The following questions ask about your household. For these questions, your household includes you and anyone else who lives with you in your place of residence (e.g. home, apartment). This includes your spouse, any other family members, or roommates.

Adults 18+ years*

Children 0-17 years*

What type of primary health insurance do you have?*

I don’t have health insurance

Marketplace / ACA / Obamacare

Medicaid

Medicare

Insured through work / employer

Other

Do you have additional health insurance?

Yes

What secondary health insurance do you have?

Marketplace / ACA / Obamacare

Medicaid

Medicare

Insured through work / employer

Other

What is your annual household income?*

$12,880 or below

$12,881 - $17,420

$17,421- $21,960

$21,961- $26,500

$26,501 - $31,040

$31,041 - $35,580

$35,581 - $40,120

$40,121 - $44,660

$44,661 - $55,000

$55,001 – $65,000

$65,001 – $75,000

$75,001+

Prefer not to answer

How comfortable are you shopping for the right (i.e., safe) foods to manage your family’s health?*

1 (Not comfortable at all)

5 (Very Comfortable)

I have difficulty obtaining safe food due to the lack of availability in my community.*

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

I have difficulty obtaining safe foods due to the high cost of the food.*

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

Over the past 12 months, how many times did you utilize an emergency food provider?*

(e.g., a food pantry)

Never

1-5 times

6-10 times

11 or more times

I have difficulty obtaining safe foods due to the high cost of the food.*

Strongly disagree

Disagree

Neither agree nor disagree

Agree

Strongly agree

Which type of community food provider have you visited over the past 12 months?*

Select all that apply

Agency

Faith-based organization (e.g., church)

Food pantry / Food bank

Hospital

School

Other

None

How many different markets, stores, pantries, or other providers (offline and online) do you typically shop for groceries?*

4 or more

Is there any additional information that you would like to share about your food needs or your food shopping experiences? (optional)

Complete this survey to activate your account
on Free From Market.

Client 1 Information

Client 2 Information

Client 3 Information

Client 4 Information

Client 5 Information

Your Household

We make it easy to get the foods you need to manage your health.

Complete this survey to activate your account on Free From Market.

Client 1 Information

Client 2 Information

Client 3 Information

Client 4 Information

Client 5 Information

Your Household

We make it easy to get the foods you need to manage your health.

Complete this survey to activate your account
on Free From Market.