I am elligible*	I am a new client It has been at least 28 days
Mark here the most significant reason you need delivery instead of coming to pick up groceries*
Full Name*
Address*
Address Line 2 (Apt./Lot/etc.)*
City*
County*
Zip Code*
Apartment Complex Name *
Email Address*
Birthdate*
Marital Statues*
Gender*
Voluntary Identify as Veteran*
Cell Phone Number*
Can we Send you Texts?*	Yes Texts No Texts
Total number of people in household*
Total number of people in household 0-5 years old*
Total number of people in household 6 years old to 12 years old*
Total number of people in household 13 years old to 17 years old*
Number people in houshold between the ages of 18 and 59*
Number people in household 60+ years old*
Full name of first additional person *
Relationship of additional person
Full name of Second additional person *
Relationship of Second additional person
Full name of third additional person *
Relationship of third additional person
Full name of Fourth additional person *
Relationship of fourth additional person
Full name of Fifth additional person *
Relationship of fifth additional person
Enter the full name, relationship, and full birthdate of any person in the household not yet listed*
Please enter the name of your home church if you have one (not required)
If you have a home church please note how often you participate (Not required)	Never Weekly or more Other Decline to answer
Identify as a Christian*
Please Send Mail-in Bible Study for all members of the family (FREE)*
Please give me access to free streaming service with 10,000+ Video Bible studies AND 2500+ Children and family-friendly shows
Do you need a new church home?*
Do you need encouragement?*
Our household income is below 200% of the Federal Poverty Limit*
Please put your full name here to attest to accuracy of all information. If you are filling this out for someone else, enter your name and cell phone number here. You are responsible to see that ALL questions are presented to the client and for accuracy*
If you are a caseworker filling this form out for a client please enter your organization information here. Please ensure all clients have had the opportunity to answer ALL questions.