Fruit & Veggie Prescription Program

Applicant Details

Approved applicants will receive 25 vouchers worth $10 each, totaling $250, to use over a 6-month period. Vouchers can be used to purchase fresh or frozen fruits and vegetables at Safeway & Albertsons stores.

Name

First

Last

If applicant is a minor, please provide parent/guardian name and phone number:

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Please confirm the address listed above is the best mailing address to receive vouchers by mail.

Date of Birth

Sex

Female
Male
Other

English speaking?

Yes
No

If no, please list language here:

Race/Ethnicity. Please check all that apply:

Monthly Income

Household Size

Primary Cancer

Residence City

Stage

Treatment City

Applicant Need & Supporting Documents

Please briefly explain how this assistance would help you and if it is medically necessary. (You may attach a file if needed or desired).

Legal

Authorizations

I give permission for my healthcare representative to release the information disclosed herein to The Journey Fund.
I give The Journey Fund permission to communicate with my healthcare representative regarding this application.
I understand this grant amount will be determined by The Journey Fund.
I give my permission for my photographs, quotes or videotape images to be used for publicity in publications or other media formatted.

In order for TJF to process this application the applicant must consent to at least the first two authorizations. *** Please note, if you consent to having your photographs, quotes or videotape images to be used for publicity/publications, TJF would contact you directly to obtain photographs/videotape images. This consent does permit us to use quotes from this application in publicity/publications.

Applicant Signature

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

Healthcare Representative Information

Name

First

Last

Email

Phone

Facility Name

Role

Verifications

I have verified that this applicant is in active cancer treatment.
I have exhausted all other resources in efforts to find assistance for the applicant.

Healthcare Representative Signature

DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application. I hereby certify that, to the best of my knowledge, the provided information is true and accurate.

*** Please note, your application will be reviewed within 30 days of the submission date. If you have any questions, please email executivedirector@journeyfund.org.