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Health and Wellness Initiative
Voucher Application
Name
Address
Email
Phone Number
Have you experienced food insecurity in the last month?
Have you experienced food insecurity in the last six (6) months?
If you are unable to pick up or shop with the voucher in person, you may appoint someone to do so on your behalf. If your proxy is applying for the voucher without you, the proxy must bring the applicant's ID with them. Proxy Name
Proxy Phone Number
Proxy's Relationship to You
Number of People in your Household
By placing my name in the field below, I declare that I have experienced food insecurity in the last six (6) months and that I am not enrolled in the SNAP program. I understand that I will be issued one set of vouchers for the 2024 market season and will not be issued replacement vouchers in the event of loss. I certify that the information I have provided in this application is, to the best of my knowledge, a true, accurate and complete disclosure of the requested information.
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