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

HMO Rebate Information:
• Keep a copy of this filled-out form.
• See www.macsac.org/rebates.html for how to claim your rebate.

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:
Share Selection:

Vegetable Share Choice(s):
Standard Share - $495 SOLD OUT FOR 2008
Every-Other-Week Standard Share - $315 SOLD OUT FOR 2008
Large Share - $685 SOLD OUT FOR 2008
Spring Share - $170 SOLD OUT FOR 2008
Storage Share - $140
Fruit Share:
$420
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 area (500 Maple Avenue)
Lafollete High area (5401 Dover Place)
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)
Shorewood (1210 University Bay Drive)
Nakoma Neighborhood (3906 Council Crest)

U.W. Health Employees (only):
University Hospital and Clinics (600 Highland Avenue)
U.W. Health (8501 Excelsior Drive)
 U.W. Health ASB (635 Science Drive)
Middleton:
Northeast Middleton (4401 Iris Court)
Central Middleton (1547 Parmenter Street)
Fitchburg: HospiceCare (5395 E. Cheryl Pkwy)
Cross Plains: 1715 Main Street
Mt. Horeb: 203 South Fourth Street
Verona: 481 Todd Street
The Farm: Hwy FF Vermont Township