Name(Required) First Last Email(Required) Address(Required) Street Address City County State AlabamaAlaskaAmerican 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 ZIP Code Which best describes you?(Required)Please click all that apply. I want to open a Food as Medicine (FAM) Food Pantry. I currently have a Food as medicine (FAM) Food Pantry. I am a healthcare organization looking to collaborate. I am a community organization looking to collaborate. Other. If you answered other, please explain below.Organization type(Required)Please click all that apply. Hospital Health Center / FQHC Community based organization Food Pantry Government Agency School or University Other If you answered other, please explain below.How would you like to get involved?(Required)Please click all that apply. Opening a Food as Medicine Pantry. Partnering with the Regional Food Bank. Learning more about The Food as Medicine (FAM) Program. Medicaid 115 Waiver Services. Other. If you answered other, please explain below.Approximately how many individuals do you serve?(Required)Please tell us about your organization and your interest in partnering with the Regional Food Bank's Food as Medicine Program.(Required)Does your organaztion currently provide food or nutrition related services? Yes No If you answered yes, please explain below.Is there any additional information you would like us to know?(Required)
