Kansas City Community Gardens Individual Membership Application

Kansas City Community Gardens Individual Membership Application

Name:______Date: ______

Mailing Address: ______

Garden Address (if different from mailing address):______

Phone: ______Email: ______

KCCG’s two membership levels are: 1) Green Card (low income) and 2) Yellow Card (not low-income). If you are not sure which level you qualify for, please call KCCG at 816-931-3877 and ask about membership income guidelines. I am applying for a: Yellow Card Membership Green Card Membership

If you are applying for a Green Card Membership, please fill out the table below for every household member:

Name / Relation to Applicant / Age / Gender / Race / Income Source / Income Amount
TOTAL

Location of Garden: How did you hear about KCCG?

Backyard I have been a member before

A Vacant Lot Friend, relative or neighbor

Community Site: ______Library

Swope Park Garden Service Organization

Freeway Park Garden Television or radio

Westport/Plaza Garden Newspaper

Eastwood Hills Garden Get Growing KC Campaign

Ivanhoe/Richardson Garden Other: ______

Research Medical Center Garden

Yes No Does anyone working in your garden have disabilities? Number: ______

Yes No Do other family members participate in the garden? Number: ______

Yes No Were you a member last year?

Yes No Did you harvest and eat some produce from your garden?

Yes No Did you eat more servings of vegetables and fruits because of your garden?

Yes No Does gardening activity help you stay more physically fit?

Garden Tilling is done by:

Self (hand/machine)

Friend, neighbor or relative

KCCG (Green Card Members living in

KCMO only- please attach proof of income).

I certify that the information given on this application is true and accurate to the best of my knowledge and belief. I understand that such information is subject to verification and I further realize that falsified or fraudulent information may result in the rejection of this application. I authorize this agency, their agents and employees to receive or provide information for the purposes of completing the application and hereby release the foregoing of and from any liability for service rendered.

Applicant Signature: ______Interviewer:______

Kansas City Community Gardens 6917 Kensington Kansas City, MO 64132 816-931-3877 www.kccg.org