Program Application

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Thanks for filling out this form. We will look at your answers to make sure Nourish Florida, offered through Simply Healthcare, is right for you. Space is limited, and spots will be filled on a first-come, first-served basis. Please respond as soon as possible. If all spots are filled, you'll be added to our waitlist and contacted if a spot becomes available. For more information, see our frequently asked questions below.

Personal Information

First Name*

Last Name*

Date of Birth*

Email Address*

Phone Number*(Used to confirm deliveries and send nutrition tips)

Food Delivery Address

Street Address*

Address Line 2(Optional)

City*

State*

Zip Code*

Household

How many people are living in your household?*

Food Allergies

Do you have any food allergies?*

YesNoNot sure

Does anyone else in your household have food allergies?

YesNoNot sure

Health Conditions

Celiac diseaseLactose intolerancePre-diabetesDiabetesHigh blood pressureChronic kidney diseaseAcid reflux (GERD)IBSHeart diseaseGoutDiverticulitisNone of theseNot sureDon't want to saySomething else

Your Health & Food Goals

Tell us about your health and food goals(Optional)

What would you like to learn about?

Making healthy choicesEating healthy on a budgetShopping healthy on a budgetHealthy recipe ideasUsing new foodsTime-saving cooking tipsHow food affects your bodyUsing food to manage your health

Consent

I want to sign up for Nourish Florida. I understand: I am signing up by choice. This will not change my Medicaid benefits. My answers will be shared with Simply Healthcare so they can see how the program works. I read and agree to these terms & conditions.

I understand: Nourish Florida will text me about my food boxes and the program. I can reply STOP any time to stop these texts. I read and agree to these terms & conditions regarding communications.