Food for Change Food Rx Application

Food Rx is a way to provide groceries at no cost to participants, stretch your grocery budget, and support your journey toward improving your health. Food Rx participants are able to receive groceries at Food for Change Markets by agreeing to eligibility requirements as specified by their current enrolled program or healthcare sites.

Participation in this program is voluntary and will not affect your standing in the sponsoring program. Thank you for taking the time to complete this application. If you have any questions or concerns, please contact your program sponsor.

Food Rx Program

Food Rx ID

Use the ID number found on your Food Rx ID card. If you do not have one, ask your program contact.

First Name

Last Name

Date of Birth (mm/dd/yyyy)

Gender Identity

Address

City

County

Zip Code

Email

Phone Number

Contact Preference (please check one):

Voice*Text*Email

*Standard data fees & text messaging rates may apply based on your plan with your mobile carrier.

Substitute Shopper Designation:

If you are unable to shop, you can select up to two Substitute Shoppers to shop for you. A Sub Shopper is a person you give permission to redeem your Food Rx. This could be a spouse, family member, or a close friend. By allowing your Sub Shopper to redeem Food Rx on your behalf, you as the participant are responsible for the actions & statements of the Sub Shopper. Please review the Food Rx Rights & Responsibilities (English version, Spanish version).

By initialing, you are acknowledging and agreeing to the Sub Shopper Policy:

Initials

Sub-Shopper #1

Name 1 (First and Last)

Sub-Shopper #2

Name 2 (First and Last)

Disclaimer

The Houston Food Bank respects your information and wants to ensure it remains private. Providing information electronically can be safer than providing information on paper. Only certain staff and volunteers can log in to the system, and each person has been trained and has signed an agreement to keep your information private. We may use your personal information for a variety of reasons:

· To improve our programs: We may use your information to improve our programs or activities. For example, staff may look at information to review the quality of services that people receive.

· To do research: We may use your information for research and analysis. Any reports produced with the data will not identify your individual information. Our staff and volunteers will only share your information with qualified persons outside of our agency.

· To connect you with other programs: At your request, we may share your personal information to see if you are eligible for other benefits or programs such as Social Security benefits or SNAP.

· To report abuse, harm or neglect: We are required by law to report any cases of suspected abuse or neglect of children or vulnerable adults. We are also required to share information about you to law enforcement in certain cases, for example, if you cause harm to a member of our staff, another client, or if you damage our property. We may also share your personal information in case of a threat to the public, such as terrorist attack or natural disaster.

Food Rx Application Agreement

By signing below I, acknowledge and confirm that the information in the Food Rx Application is complete & correct. I understand that purposely giving false or misleading information may result in disqualification of Food Rx. By signing below, I am agreeing to the terms and conditions laid out in the Participant's Rights & Eligibility Section. By signing below, I am also providing Houston Food Bank permission to contact me electronically, including surveys concerning program participation and quality and updates regarding program participation and operations.

Food Rx Recipient Signature:

If this form was completed by program staff, please type proxy name below:

Proxy Signature:

If Food Rx recipient is a minor, their parent/guardian needs to complete below:

I (Parent/Guardian) grant permission for my child to participate in the Food Rx program. I certify that I have read and understood all information on applicable forms, and allow my child to participate unless I provide verbal and/or written consent to the program staff to discontinue. I understand my rights and responsibilities as stated above.

Parent/Guardian Signature:

After choosing "Submit," you will be redirected to complete the baseline survey for Food Rx.