Fill out this form and mail with payment to:
Vermont Valley Community Farm, 4628 Cty Hwy FF, Blue Mounds, WI 53517

Personnal Information:     If you are splitting this share with another household, please give their contact information also.
Household 1 Household 2

Name(s): (This name will
                identify the share.)
                 
Address:
                 
Phone:         
E-mail:

Name(s):
               

                 
Address:
                 
Phone:         
E-mail:
2011 Share Selection:

Vegetable Share Choice(s):
Standard Share - $570
Every-Other-Week Standard Share - $365
Large Share - $770
Spring Share - $195
Storage Share - $165
Fruit Box:
$445
Food-To-Share:
$100
Asparagus to Zucchini Cookbook:
$15
Assistance Fund Donation:          Total Due:

Pick-Up Site (please select ONE):

East Madison:
Just Coffee Roastery (1129 E. Wilson Street)
Marquette area (1304 Jenifer Street)
Tenney-Lapham area (332 N. Baldwin)
Atwood/Circle Park area (2317 Oakridge Ave)
Atwood/Barrymore area (157 Jackson Street)
West Madison:
Crestwood Neighborhood (204 Bordner Drive)
Monroe Street area (2213 West Lawn)
Vilas area (1716 Jefferson Street)
West High area (2809 Mason Street)
Beltline and Whitney Way (1009 Hampshire Place)
Raymond and Whitney Way (41 Black Oak Circle)
Shorewood (1210 University Bay Drive)
Nakoma Neighborhood (3906 Council Crest)
 University Hospital and Clinics (600 Highland Avenue) U.W Health Employees only
Research Park (595 Science Drive)*
*Pick-up time 4:00 -5:30 pm

Middleton:
Every Other Week shares only (2214 Parmenter Street)
Standard and Large shares only (1547 Parmenter Street)
 Middleton Hills area (6622 Whittlesey Rd.)
Monona: 6019 Queens Way
Fitchburg:
 HospiceCare (5395 E. Cheryl Pkwy)
Seminole (2913 Walnut Wood Ct)
Cross Plains: 1715 Main Street
Mt. Horeb: 203 South Fourth Street
Verona: 481 Todd Street
The Farm: Hwy FF Vermont Township

HMO Rebate Information:
• Keep a copy of this filled-out form.
• See www.macsac.org/rebates.html for rebate details.
Check your insurance provider:
Physicians Plus
Group Health Cooperative
Dean Health Plan
Unity Health Insurance
If your insurance provider is not listed, contact them to ask if they offer a rebate, and if not - why not?