Help us collect a little information about the Timmins Good Food Box program. Thank you for your time!

Please circle the answer that best applies to you.

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* Select your appropriate age group:

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* Select your gender:

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* Including myself, the number of individuals in my household is:

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* Of the number of individuals in my household, the number of children under the age of 12 is:

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* Please select the appropriate income bracket:

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* In one year, I purchase approximately ____ Good Food Boxes:

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* I purchase the Good Food Box because (select all that apply):

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* Host Sites are a way of making the program more accessible and convenient for individuals who wish to order. When I am at a Host Site I find that (check all that apply):

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* Please select the statement that best applies: I have ordered the Good Food Box...

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* I read the newsletter and use the recipes that are included in the box each month:

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