Pre-Registration Form for Food Assistance (English)

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If you would like to register to receive food from Feeding Hands Pantry, please complete all questions below (* are required). 

You must provide a phone number or email to get your appointment.

Who is the head of household that will pick up the food? *

First name
Last name
Date of birth (mm/dd/yy)

Household information: *

Total number of people in household
Number of adults age 60 or over
Number of children under 18

Household address: *

Street address
Apt/floor
City
Zip code
County:
If County = "Other", What County do you live in?your full name
Are you receiving any of the following governmental assistance?Check all that apply.
Was your family income reduced because of COVID-19? *
Are you having difficulty affording your housing or other basic needs? *

Contact information:

Either phone number or email is required to get your appointment.  If you do not have a phone, please provide the number of someone who can get messages to you.

Phone number *
Is this a cell phone number? *
Do you want to receive your client number and appointment time via email or text? *
Select a timeframe/location for your appointment: *
Conditions to Receive Assistance *As conditions for receiving assistance, I acknowledge, consent to, and certify the following: (Check all to acknowledge your agreement.)

Client Signature:  

By typing your full name, you acknowledge, consent, and certify to the above information.

By typing your full name, you acknowledge, consent, and certify all details.
Date (mm/dd/yy)

Next Steps:

  1. If you provided an email address, you will immediately receive an email confirmation from hello@feedinghandspantry.org.  Please check your Junk Email folder if you do not see the message in your Inbox.
  2. Within the next few days, you will receive a client number (required at your first appointment) and appointment day and time via email or text. You can receive food once a month by appointment.

Please bring the following to your appointments:

  • Client card (you will receive this on your first visit)
  • Photo ID
  • Proof of address (electric bill, phone bill, or other document with your name and physical address)

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