Pantry Supplies Program application

Name*

First NameLast NameSuffix
Email*
example@example.com
Street Address*
City*
State*
Zip Code*
Phone Number*
How many members are in your household?*
Is any member of your household employed?*
What is your household monthly salary?*
What demographic describes your household? Check all that apply.*

Single Parent HouseholdVeteran/Active DutyPerson with a DisabilitySenior Age 55+Person in a Domestic Violence SituationPerson Impacted by a Natural DisasterOther
Race/Nationality*
How did you hear about us?*
Please check every choice that applies to your family below so that you can receive the appropriate supplies for your household.*

Men supplies neededWomen supplies neededGirl child supplies neededBoy child supplies neededBaby supplies neededPre-Teen/Teen supplies needed
Which public assistance do you receive? Check all that apply.*

SNAP/EBTTANFChild SupportSocial SecurityUnemploymentRental AssistanceUtility AssistanceOther
Please let us know of any special needs or concerns.
If you need Diapers or Depends, etc. please include the size in the box above. Failure to specify needed items will result in incorrect items being sent to your family.
The information in this form will be kept confidential. Demographic information is used to collect data for funding. I understand that orders can be placed once every 3 months. After two consecutive orders, I understand I will be enrolled in financial management services provided by Kinfolk Coaching at no additional charge to me (pending available funding). I agree to these terms*
Please upload a picture of your photo ID. If you do not upload a picture to this form, please email a picture of your photo ID to village@kinfolkcoaching.org with your first and last name as the subject.

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Please complete the budget worksheet. Submitting an application without a budget will automatically deny you from receiving a box.*
Thank you so much for completing your application for the Pantry Supplies Program. We work hard to get boxes out as soon as possible. Please note, pending funding and item availability, it may take 3-4 weeks before we can ship your box to you. If you are local and in the North Charleston and surrounding areas, we may reach out to meet you at a Pickup location. Please review your application to ensure you are being as specific as possible in requesting your family's needed items. Thank you so much for your patience.

-Kinfolk Coaching

www.kinfolkcoaching.org
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