Registration "*" indicates required fields 1234 Your First Name* Your Last Name* Email* State* SelectAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State HiddenZip Code Password* Enter Password Verify Password Strength indicator Minimum of 10 characters long and contain at least one uppercase and one lowercase letter (A,z), one numeric character (0-9), and one special character (such as !, %, @, or #)HiddenWere you referred by your physician, health plan or another organization? Yes No Enter your 10-digit Invite Code:*You can find your invite code in your welcome email. Include hyphens when entering the code. Add Family MembersClick the “Add Family Member” button to list each person in your household who has any health-related dietary restrictions (e.g., food allergies, diabetes, GI disease). Include yourself if you have a dietary restriction. Name Date of Birth Gender Actions Edit Delete There are no Family Members. Add Family Member Maximum number of family members reached. Tell us about your household Include everyone who lives with you in your place of residence (e.g. home, apartment). This includes your spouse, any other family members, or roommates.How many Adults currently live in your household?*Adults 18+ yearsEnter a number012345678910How many Children currently live in your household?*Children 0-17 yearsEnter a number012345678910What is your annual household income?* $12,880 or below $12,881 - $17,420 $17,421- $21,960 $21,961- $25,500 $26,501- $31,040 $31,041- $35,580 $35,581- $40,120 $40,121- $44,660 $44,661- $55,000 $55,001- $65,000 $65,000- $75,000 $75,000 + Prefer not to answer Does anyone in your household eat or avoid specific foods based on their religious beliefs?* Yes No Prefer not to answer Other 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 No Additional Health Insurance Marketplace / ACA / Obamacare Medicaid Medicare Insured through work / employer Other Which language(s) do you speak?* English Spanish Chinese (e.g., Mandarin, Cantonese) Tagalog Vietnamese French Arabic Korean Russian Other Select all that applyOther Language How comfortable are you shopping for the right (i.e., safe, healthy) foods to manage your family’s health?*Very uncomfortableSomewhat uncomfortableNeutralSomewhat comfortableVery comfortableI have difficulty obtaining safe/healthy foods due to the high cost of the food?*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI have difficulty obtaining safe foods due to the lack of availability in my community?*Strongly disagreeDisagreeNeutralAgreeStrongly agreeHow many different markets, stores, or pantries (offline and online) do you typically shop for groceries?* 1 2 3 4 or more 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 received education on how to choose healthy foods and/or read food labels for myself and my family in the past.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeI am comfortable informing my friends and family on how to make healthy food choices based on my current knowledge.*Strongly disagreeDisagreeNeutralAgreeStrongly agreeIs there any additional information that you would like to share about your food needs or your food shopping experiences? (optional)Nutritional CoachingIn addition to shopping on Free From Market, you also qualify for free 1-on-1 nutritional coaching sessions online. After you complete this form, you’ll receive an email with instructions on how to schedule your first session. Mobile Phone* Consent I agree to receive SMS text notificationsTo ensure you never miss an upcoming coaching session or any important updates about your orders, we kindly request your consent to receive text notifications from us. By opting in, you'll stay informed and connected. Please note that standard text and data rates may apply as per your mobile service provider.
