ALSEA VALLEY GLEANERS___________________

Are you now or ever been a member of another Gleaners group?  Y/N______________________________

New Applicant (YES) ____ (NO) ____     Date___________________________

NAME_________________________________ ADDRESS_________________________________________

PHONES (HOME) _______________ (CELL) ______________ EMAIL: ________________________________


Children under 18? _____Veteran?________

In order to receive donated food or firewood you must have a household equal to or below 200% of the poverty guidelines set for Oregon. The chart on the last page helps determine if you’re eligible to receive donated food and/ or firewood.



_______ Gleaners is a self help program; it is not a food box agency.  A minimum of _10_ hours of volunteering each month, per household is required for gleaning households. If a gleaner household fails to complete the required monthly volunteer hours for three months, the household will be terminated from gleaning group.  

Food is allocated and distributed by household size

Your ability to pay dues or give DONATIONS DOES NOT affect your ability to receive food


DO YOU HAVE A (TRUCK) _______   (VAN/SUV) __________ (CAR) __________

Office Only

________GLEANERS                                                                                ______ADOPTEE


DO YOU BURN WOOD (YES) ______ (NO) ________DO YOU HAVE PETS    (DOGS) _______ (CATS) _______ (OTHER)





The definition of Adoptee is a household where no adult member is either physically or mentally capable of performing the gleaning group hours of required service. Adults are defined as those who have attained the age of 18 or are no longer enrolled in or eligible for high school. Additional consideration for adoptee status may be considered by the gleaning board.

Please read carefully and Initial on the line that you understand and agree with the following terms. Please ask if you need help.




2______ Members are required to participate on field and back yard gleans.

3.______ Gleaners insists on maintaining a safe, respectful, gossip-free environment at all our functions. If there is a problem, you will be asked to leave the site.

4.______If you do not PARTICIPATE in distribution for (3) weeks in a row or make arrangements prior, your membership will be revoked without notice and you will need to reapply if you wish to be reinstated. 

  1. _______ Gleaners is a self-help organization committed to utilizing the skills and abilities of its membership.

6._______ Gleaners will not tolerate Discrimination with regard to Race, Color, National Origin, Religion, Disability, Sexual Orientation, or Gender Identity.

In accordance with IRS regulations, your ability to pay or donate does not affect the amount of food you receive

Waiver of Liability

I understand that Alsea Valley Gleaners is designed to let me pick left over crops from farmer’s fields  and/or obtain firewood in a similar manner and that I must treat the donor’s property with respect and care. I understand that the crops or wood I will receive are a generous donation. I understand that 50% of what I pick will go to adoptees.
With this knowledge, I ____________________________, and anyone accompanying me, do hereby expressly agree that all our activities shall be at our sole risk and that neither  Alsea Valley Gleaners nor the donors whose property we enter shall be held liable for any claims, demands, injuries, damages, actions, or cause of action whatsoever, to person or property arising out of or connected with our participation in this organization.

By my signature, I am stating all preceding information is true to the best of my knowledge and agrees to all the rules and regulations of Alsea Valley Gleaners. I affirm that my households qualify to receive food and firewood under the economic guidelines on the front page of this application.

SIGNATURE: ___________________________________ DATE: ______________________


INTERVIEWED BY: _______________________________ DATE: ___________

APPROVED AS:       GLEANER: ___________        OR          ADOPTEE: __________


The U.S. Department of Agriculture prohibits discrimination against its customers on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, in any program or activity conducted or funded by the Department.  (Not all prohibited bases will apply to all programs and/or employment activities.

If you wish to file a civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at, or at any USDA office, or call (866) 632-9992 to request the form.  You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at .






Family Size

Month Annual
1 $2,023 $24,280
2 $2,743 $32,920
3 $3,463 $41,560
4 $4,183 $50,200
5 $4,903 $58,840
6 $5,623 $67,480
7 $6,343 $76,120
8 $7,063 $84,760
*Add for each family member over 8 $360 $4,320



2018 Income Guidelines 200%


Alsea Valley Gleaners


I authorize Alsea Valley Gleaners (AVG) and those acting pursuant to its authority, to:

(a) Record my participation and appearance on videotape, audiotape, film, photograph, AVG’s web site, blog or other social media or record in any other medium.

(b) Use my name, likeness, voice and biographical material in connection with these recordings.

(c) Exhibit or distribute such recording in whole or part without restrictions or limitation for any educational or promotional purpose that Alsea Valley Gleaners and those pursuant to its authority deems appropriate.

(d) To reproduce and distribute printed materials using my name and likeness or my dependant’s name and likeness for educational or promotional purposes.

(d) Waive any right I might have to inspect and/or approve the finished medium or the use to which it may be applied. I acknowledge Alsea Valley Gleaner’s right to crop or treat the medium at its discretion.

I represent that I am at least 18 years of age and that I have read the above and fully understand the above paragraph and knowingly and voluntarily execute this release.


Name: _________________________________________________________________________________

Signature: _______________________________________________________________Date___________