If you have been affected by COVID-19 in any way please submit this form and we will contact you within 48 hours.
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Date of Birth
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Number of Adults in Household?
*
How many adults currently live in your home?
Ages 18-25
Ages 26-50
Age 50+
Number of Children in Household?
*
How many children currently live in your home?
Ages 0-5
How many kids do you have in this age group?
Ages 6-12
How many kids do you have in this age group?
Ages 13-17
How many kids do you have in this age group?
Are you currently homeless?
Yes
No
Do you receive Veterans Benefits?
Yes
No
Marital Status
Married
Single
Divorced
Ethnicity?
-----------------Asian
Black/African American
Caucasian
Hispanic
Middle Eastern
Native American
Alaska Native
Native Hawaiian
Pacific Islander
Other
Hispanic Origin
*
Yes
No
Education Level
High School/GED
High School - Incomplete
College
Do you have income?
*
Yes
No
Income Sources
*
Employment
Child Support
TANF
SSI
Disability
Amount?
*
How Often Received?
*
-------------------
Weekly
Bi Weekly
Monthly
Yearly
Back
Next
Needs Assessment
The following section will help us determine how we can better serve you.
Have you or anyone in your household been affected by COVID-19
*
Yes
No
Do you have any food allergies or restrictions?
*
Yes
No
If yes, what foods should we avoid?
Are you in need of infant care products?
Yes
No
If yes, what's your biggest infant need?
Infant Formula
Baby Food
Pampers
What kind of baby formula do you use?
Tell us what kind of formula you use, we will try to get the closest to that.
If you need pampers, what size?
Newborn
Size 1
Size 2
Size 3
Size 4
Size 5
What are your 4 biggest household needs at this moment?
Tissue
Paper Towels
All Purpose Cleaner
Bleach
Dish Soap
Comet
Toilet Bowl Cleaner
Soap
Band-Aids
Toothpaste
Toothbrush
Kids Toothbrush
Kids Toothpaste
Are you in need of Cat or Dog Food?
Yes
No
How many Cats?
0
1
2
3
4
5+
How many cats do you currently own?
How many Dogs?
0
1
2
3
4
5+
How many dogs do you currently own?
Do you have expenses?
Rent
Lights
Water
Gas
Life Insurance
Car i.e. gas, upkeep, insurance
Rent Amount
*
Lights Amount
*
Water Amount
*
Gas Amount
*
Life Insurance Amount
*
Car Expenses Amount
*
Are you currently behind on an of the following bills?
Rent
Mortgage
Lights
Water
Gas
We partner with local agencies that can assist with these needs, do you need a referral?
Yes
No
If yes, for what Bills?
Rent
Mortgage
Lights
Water
Gas
What Amount is Due?
Back
Next
Benefits
What benefits are you currently receiving? If none and you would like to check your eligibility, let us know below.
Do you currently receive SNAP benefits?
Yes
No
Would you like to apply for SNAP benefits?
Yes
No
Do you currently receive TANF?
Yes
No
Would you like to apply for TANF?
Yes
No
Do you currently receive Medicaid or Medicare?
Yes
No
Would you like to apply for Medicaid or Medicare?
Yes
No
Do you currently receive WIC?
Yes
No
Would you like to apply for WIC?
Yes
No
Do you need a replacement?
Birth Certificate
Social Security Card
None
Back
Next
Lifestyle
Let us know how you feel about the topics below. We may have programs and services that can assist you in living a healthy lifestyle.
I Enjoy Cooking
1
2
3
4
5
I Try to Eat Healthy Foods
1
2
3
4
5
I am interested in Healthy Recipes
1
2
3
4
5
I am interested in Health & Wellness
1
2
3
4
5
Would you be interested in a FREE Health & Wellness workshop?
Yes
No
Submit
Should be Empty:
Now create your own JotForm - It's free!
Create your own JotForm