Angel Food Program Registration Form
Thank you for your interest in the Angel Food Project (AFP). AFP is a program designed for women directly affected by incarceration and the criminal legal system. The Ladies of Hope Ministries (LOHM) is committed to excellence through diversity regardless of race, ethnicity, religion, or lived experiences. The demographic information we are gathering in this form will only be used to better serve our participants, we do not share program data. Thank you in advance for completing this form. *Required
Program ID
What is your Full Name
*
First Name
Middle Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list your Primary Phone Number
*
-
Area Code
Phone Number
Email Address
*
Date of birth
*
-
Month
-
Day
Year
Date
What is your gender identity?
*
Female
Male
Transgender
Non-binary
Prefer not to say
Ethnicity
Hispanic or Latino
Not Hispanic or Latino
How would you best describe yourself?
*
Native American
Black
Pacific Islander
White
Multi-Racial
Hispanic/Latinx
Asian
Other
How many children under the age of 18 live in your household?
*
None
One
Two
Three
Four
Five
More than five
Have you or a Family Member been impacted by incarceration? Please select all that apply.
*
Yes
No
If so, please select all that apply.
Myself
Spouse
Parent
Sibling
Other
Current Income Range
*
Unemployed
$25,000 or less
$25,000-$50,000
$50,000-$75,000
$75,000 or more
Are you currently enrolled in the Supplemental Nutrition Assistance Program(SNAP)?
Yes
No
Number of members living in your household?
1
2
3
4
5
6
7 or greater
First Additional Household Member Information
Additional Household Member #1
First Name
Last Name
Household Member #1 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #1 Date of Birth
-
Month
-
Day
Year
Date
Household Member #1 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #1 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #1 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Second Additional Household Member Information
Additional Household Member #2
First Name
Last Name
Household Member #2 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #2 Date of Birth
-
Month
-
Day
Year
Date
Household Member #2 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #2 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #2 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Third Additional Household Member Information
Additional Household Member #3
First Name
Last Name
Household Member #3 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #3 Date of Birth
-
Month
-
Day
Year
Date
Household Member #3 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #3 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #3 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Please list any additional household members here:
Fourth Additional Household Member Information
Additional Household Member #4
First Name
Last Name
Household Member #4 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #4 Date of Birth
-
Month
-
Day
Year
Date
Household Member #4 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #4 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #4 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Fifth Additional Household Member Information
Additional Household Member #5
First Name
Last Name
Household Member #5 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #5 Date of Birth
-
Month
-
Day
Year
Date
Household Member #5 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #5 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #5 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Sixth Additional Household Member Information
Additional Household Member #6
First Name
Last Name
Household Member #6 Relationship
Child
Spouse
Parent
Sibling
Other
Household Member #6 Date of Birth
-
Month
-
Day
Year
Date
Household Member #6 Gender Identity
Female
Male
Transgender
Non-binary
Prefer not to say
Other
Household Member #6 Ethnicity
Hispanic or Latino
Not Hispanic or Latino
Household Member #6 Race
American Indian or Alaskan Native
Black
Pacific Islander
White
Multi-Racial
Other
Please list any additional household members here:
End of Additional Household Member Information
Do you or any other household members suffer from food allergies or have any dietary restrictions? (Select All That Apply)
Peanut allergy
Seafood allergy
Gluten allergy
Vegan diet
Vegetarian diet
Other
Do you or any other household members have any health concerns or bodily illnesses?(Select All That Apply)
Diabetes
High blood pressure
Heart disease
Asthma
Cancer
Other
Please Select the days and times that are most convenient for pick-up or delivery
Monday-Friday only
Weekends only
Any day
Mornings/afternoons
Afternoons/evenings
Any time
Please select the location(s) that are most convenient for pick-up
Brooklyn
Bronx
Queens
Upper Manhattan
Lower Manhattan
Staten Island
How did you hear about this program?
*
The LOHM Website
LOHM employee
Social media
Other
Or, referred by:
Do you know someone that can benefit from this program? If yes, please provide their name and contact number below so we my follow-up for information. (Please note, all data or information collected stays within the Ladies of Hope Ministries Organization, and will not be shared with the public).
Submit
If you have questions please contact Annie Reynoso - annie@thelohm.org
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