Fresh Food Box and Prepared Meal Signup Form

Rhema Word Foundation

(aka) Rhema Wings
Fresh Food Box or Prepared Cooked Meals

Helping Hand Food Program
Name of Applicant*

PrefixFirst NameMiddle NameLast Name
Applicants Birthdate*

MonthDayYear
Applicants Phone Number*

Area CodePhone Number
Applicants E-mail Address*
Applicants Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you have any minor children in your household? Yes/No*
If so, how many *
Are you Disabled? blanks*
Are you caring for a senior parent or a loved one? Yes/No*
Income Eligibility Criteria

(To be eligible for a cooked prepared meal or a fresh food box, you must complete the following)
Select which of the following you receive:*

MedicaidFood & Nutrition (EBT)Social Security Disability or SSIUnemploymentSingle ParentAbuse SurvivorIndependent Senior Citizen (65 years old or Older)
Program Case or ID#
If applicable
Helping Hand Food Program Options*
prevnext( X )
Prepared Meal $ Free
Healthy and wholesome cooked meal. Meals are prepared by From the Heart Catering and Meal Prep; Chef Angelia Drake and according to the CDC guidelines.

Quantity (One meal per person indicated on application)

Fresh Food Box (please note: option is not guaranteed, it depends on resources Also, we DO NOT deliver fresh food boxes on Monday's. )$ Free
Cheese, milk, fruit, potatoes, onions, a protein. (please note: option is not guaranteed, it depends on resources Also, we DO NOT deliver fresh food boxes on Monday's. )

Either Option $ Free
You chose either option, which means a prepared meal or a fresh food box will be delivered based on available resources. (One meal per person indicated on application)

Quantity (One meal per person indicated on application)Prepared Meal Quantity
Which delivery day is better for you? (Delivery Times Varies between12:00 pm. - 2:30 pm.)*

Monday (Prepared Meals ONLY)WednesdayFriday
If you are not home during time of delivery, would you like box/ meal left in a secure area (neighbor. porch, chair)?*

YesNo
SECURELOCATION:
If you are not home to receive box/ meal, where do you want us to leave it? (We are not responsible for perishables left out of refrigerator) blanks*
Are you a victim of abuse and need assistance?*

YesNo
Are you a survivor of abuse and would like to become a mentor?*

YesNoMaybe Later
*Please Read Carefully

The Rhema Word Foundation is proud to serve as a donation site for survivors of adult and child abuse, single parents, and senior citizens with nutrition, counseling, and financial resources and have partnered with Lighthouse Ministries, From the Heart Catering, and East End Community Development Corp to make this Helping Hand Food program a success.

. Each application is submitted as a request and therefore not guaranteed. All application decisions are granted at the sole discretion of the Rhema Word Foundation and its partners. Please fill out all the required information so we can keep you updated on your application status. To ensure that all approved applicants are served, a government-issued ID is required.

If you have any questions please leave it in the box below.
Comments or Questions:
Electronic Signature*
First and Last Name
DateTime
Should be Empty:

Rhema Word Foundation

Fresh Food Box or Prepared Cooked Meals