Healthy Eating and Tasting Program Voucher Application

Please enter YOUR information below. (The person who is completing this online application.)

*** If you are applying for someone else, you will have opportunity on the next page to enter their information. ***

IMPORTANT NOTE: The voucher for a successful application will be mailed to the address provided on this page.
Enter your name * Required
First Last
Enter your address * Required
Street Address City State ZIP
Enter your email address * Required
Enter your telephone number * Required
This application to receive a Schmieding Center voucher to a local Harps™ Food Store is for: * Required
- Me
- Someone else

This application is for the person named below to receive a Schmieding Center / Harps Food Store voucher to purchase recipe ingredients in the UAMS Center on Aging Healthy Eating and Tasting Program.
This application is for you to receive a Schmieding Center / Harps Food Store voucher to purchase recipe ingredients in the UAMS Center on Aging Healthy Eating and Tasting Program.
Name of voucher recipient * Required
First Last
Enter address of voucher recipient * Required
To send a voucher to your address from the previous screen on behalf of the person named above, a valid address must be provided below for delivery of the voucher or of purchased items to the voucher recipient. If you plan to shop for this person, the Schmieding Center will confirm their receipt of purchased items by calling the voucher recipient.

Street Address City State ZIP
Email address of voucher recipient * Required
If unavailable, you should enter your email address again here
Phone number of voucher recipient * Required
A valid phone number must be provided below for the voucher recipient. The Schmieding Center will contact the voucher recipient to confirm delivery of the voucher or of the purchased items.
Enter demographic information below
Residence County of voucher recipient * Required
Gender of voucher recipient * Required
Race of voucher recipient * Required