Plant Medicine Coalition Application Plant Medicine Coalition Application 12345 All Together Now PA: Plant Medicine Coalition ApplicationAdvocating local independent ownership. Building local supply chains. Seeking economic justice.Name* First Last Email* Mailing address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*Choose OneAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkI don't live in PennsylvaniaMobile phoneMy interest in Plant Medicine falls into the following category (or categories):* Medical marijuana Adult use cannabis Herbal medicine CBD Other Were you referred by a member of the coalition? If so, whom?(If it was not a member, tell us how you found out about us.) DemographicsWhat are your preferred pronouns? She/her He/His They/their Ze/zir What is your age group? 18 - 24 25 - 34 35 - 44 45 - 54 55 - 64 65+ What is your race? Asian Black or African American Native American or American Indian Native Hawaiian or Other Pacific Islander White Multiple Races Prefer Not to Answer What is your ethnicity? Hispanic or Latinx Not Hispanic or Latinx Relationship to Plant MedicineWhat is your relationship to plant medicine?* Plant medicine-related business owner Plant medicine grower Plant medicine healer Plant medicine researcher/student/writer Plant medicine advocate Other Plant Medicine-Related BusinessName of your business Business physical address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Website What is your role in the business? Majority Owner Minority Partner/Owner Employee Do you live within 50 miles of your business? Yes No Please briefly describe your business in one or two sentences:Do you currently buy locally grown plant medicine? Yes No No, however I would like to Where are your customers located? Within the region near your business location Within the state Within the northeast region Nationwide Globally Online distribution Are you interested in developing more customers within your region and within our state? Yes No Plant Medicine GrowerName grower business or farm Farm physical address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyChoose OneAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkI don't live in PennsylvaniaWhat is your farm role? Majority Owner Minority Partner/Owner Employee Do you live on the farm? If not, how many miles away do you live? What plant medicine crops do you grow?Plant Medicine HealerName of your practice Website Business physical address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyChoose OneAdamsAlleghenyArmstrongBeaverBedfordBerksBlairBradfordBucksButlerCambriaCameronCarbonCentreChesterClarionClearfieldClintonColumbiaCrawfordCumberlandDauphinDelawareElkErieFayetteForestFranklinFultonGreeneHuntingdonIndianaJeffersonJuniataLackawannaLancasterLawrenceLebanonLehighLuzerneLycomingMcKeanMercerMifflinMonroeMontgomeryMontourNorthamptonNorthumberlandPerryPhiladelphiaPikePotterSchuylkillSnyderSomersetSullivanSusquehannaTiogaUnionVenangoWarrenWashingtonWayneWestmorelandWyomingYorkI don't live in PennsylvaniaWhat is your role in the practice? Majority Owner Minority Partner/Owner Employee Do you live within 50 miles of your practice? Yes No Do you currently use locally grown plant medicine? Yes No No, however I would like to Please briefly describe your practice in one or two sentences:Plant Medicine/Cannabis AdvocateAre you affiliated with any advocacy groups or organizations? If yes, please describe below.In what ways are you advocating for plant medicine and/or cannabis?Plant Medicine Researcher/Student/WriterPlease share the name of school, institution or publication: Please describe your role:Other Relationship to Plant MedicinePlease describe your relationship to plant medicine: All Together Now PAWhat do you hope to gain from being a part of the coalition?Are you interested in teaching others in any of the following areas? Cultivation Harvesting Drying & storage Processing Extraction Co-packing / labeling Lab Testing Healing / benefits of plant medicine I am not interested in teaching at this time. Other Please describe what other topics you are interested in teaching: Are you interested in learning more about any of the following areas? Cultivation Harvesting Drying & storage Processing Extraction Co-packing / labeling Lab Testing Healing / benefits of plant medicine I am not interested in participating in educational programs at this time. Other Please describe what other topics you are interested in learning: Are you interested in volunteering your time? If so, what would you like to do? Host meetings at your business, farm or organization Help to organize public events Speak at public events Teach others your skills/knowledge Help strategize and organize the coalition I am not interested in volunteering at this time Other Please describe what other ways you are interested in volunteering: Alignment of ValuesThe Plant Medicine Local Supply Chain Coalition seeks alignment of our members around basic values in order to work collaboratively toward creating the world we want to live in and pass on to future generations. Please provide your values and beliefs to each of the following core areas.We support the local production of our basic needs, such as food, fuel and fiber, by locally owned farms and businesses in order to build community wealth and local economic power. Are you with us? Yes No Maybe Please share your values and beliefs in regard to the above.We work to decrease our reliance on long-distant corporate supply chains in order to increase regional self-reliance and resiliency. Are you with us? Yes No Maybe Please share your values and beliefs in regard to the above.We value economic justice and work to build an inclusive economy that provides opportunity for economically marginalized communities, such as small farmers, immigrants, entrepreneurs of color, women, veterans and returning citizens, in both rural and urban communities. Are you with us? Yes No Maybe Please share your values and beliefs in regard to the above.We believe that adult use cannabis should be legalized in our state. Do you agree? Yes No Maybe Please share your values and beliefs in regard to the above.We believe that exit strategies should be designed to maintain local independent ownership of farms and businesses as much as possible. This can be done by selling to employees, family members, other local entrepreneurs or farmers, or to a community land trust or non-profit, as opposed to selling to large out-of-state corporations. Do you agree? Yes No Maybe Please share your values and beliefs in regard to the above.We work to build a conscious economy where business decisions are not made to maximize profits and material gain, but to maximize the health and well-being of our communities and eco-systems, while making a fair profit. Are you with us? Yes No Maybe Please share your values and beliefs in regard to the above.We believe that business relationships should reflect the values of cooperation, generosity, fairness, integrity, compassion, and respect for all people, nature and other species. Do you agree? Strongly agree Agree Neutral Disagree Strongly disagree Please share your values and beliefs in regard to the above.Is there anything else you would like us to know or do you have any questions? Δ
