Food Rx Self-Enrollment Form

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What you eat may be the most important tool you have to manage your diabetes. Making healthy food choices can help you improve your blood sugar and reduce complications. Everyone with or at risk of developing diabetes can benefit from eating more fruits and vegetables.

Houston Food Bank’s Food for Change program offers 6 months of FREE fresh produce and nutrition education to support you and your family’s health. Redeem up to 60 lbs. of produce per month while learning how to manage diabetes.
Food Insecurity Screening
For the next two questions, please indicate how accurate the following statements are for you/your household.


Food Rx Interest Form
Based on your responses, you're eligible to enroll in the HFB Food Rx Program. Please complete the questions below to complete your enrollment into the program.


Food Rx Enrollment




If you are not at least 18 years old, your application will not be processed








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Choose as many as apply.


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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:


Sub-Shopper #1

Sub-Shopper #2

Sorry to see you go! Since you've selected that you are not interested in enrolling in the program, you may close out of this window in your browser to discontinue your application.

If you change your mind, you can access this application at any time to enroll in Food Rx.
Thank you for your interest in Food for Change!

Food Rx is designed to serve individuals experiencing Food Insecurity in the Greater Houston Area. Since you answered "Never true," to both questions on the Food Insecurity screener, you are not eligible to enroll in the program.
Food Rx Agreement
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.

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.
After choosing "Submit," you will be will redirected to an acknowledgement page with your new Food For Change ID.