GRACE Thanksgiving Box Registration Form

Application Date*

Date

Reason you were not able to register in person:*

Name*

First NameLast Name

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone*

Please enter a valid phone number.

Phone Type

CellHome

Other Phone (Specify Relationship)

Please enter a valid phone number.

Phone Type

CellHomeWork

Email

example@example.com

How long have you resided at this address?

We need to ask some household questions that will be kept on record by the GRACE office used for reporting information necessary for grants as well as reporting general statistics. No names will be reported for these purposes. However, information may be shared with all parties necessary to verify information or determine eligibility. GRACE does not discriminate based on age, sex, race, color, handicap, religion, or national origin.

HOUSEHOLD INFORMATION

How may people reside in your household?

Household Information

	Full Name	Relation	DOB	Age	Race	Known Food Allergies
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6
Other Members

Sources of Income for your household.

	Source	Amount	Verified
1
2
3
4

Do you need to have your Thanksgiving box delivered?

YesNo

Provide any special delivery information here:

CONSENT FORM

I understand that this is an outreach program sponsored by Greene Alliance of Church and Community Efforts, Inc. (GRACE) and that it is supported by our local agencies, churches, schools, civic organizations, businesses and individuals in our community. I certify that the information provided is true and correct. I understand that, if I have knowingly given false or misleading information in the completion of this application, I can be denied this service. I give GRACE permission to verify my confidential information with other agencies, schools, employers, etc. Any discussion or release of information will be solely for the purpose of determining eligibility for the Thanksgiving Box Program.

The above-named parties are hereby released from all legal liability that may arise from the release of the information requested.

I understand that this consent is subject to revocation by me at any time and, unless an earlier date is specified, that it automatically expires one (1) year after the date below.

I also understand that without my consent, GRACE will not be able to assist me through the GRACE Thanksgiving Box Program.

Applicant Signature*

Date of Signature*

Date

THANKSGIVING BOX PROGRAM DISCLAIMER

Families signed up to receive a Thanksgiving Box must pick up their food box on the designated distribution day and between the hours specified. Food boxes not picked up by closing time on distribution day will be forfeited and given to another family in Greene County needing this assistance.

Thanksgiving Box recipients are responsible for accurate contact information and keeping their phones active in case GRACE needs to contact the family for additional information. GRACE’s inability to contact you may result in your requests not being honored.

If you are requesting that your box be delivered, please make sure that you will be home during the time that has been arranged for your box to be dropped off at your home.

If you designate someone else to pick up your box, that person must bring your family card, their ID and a letter signed by you authorizing them to pick up your box; otherwise, the food box will not be released to them. The person picking up your box will be asked to show their ID. If someone else picks up your food box on your behalf, GRACE does not guarantee that the box contents you receive are the same as those give to your authorized pick-up person.

GRACE has asked you to provide us with some information that we would like to explain:

1. Your picture ID (usually your driver’s license) helps our volunteers verify that you are who you say you are and that you live in Greene County. If your address is not correct on your driver’s license, or does not show your current physical address, please present other proof of your address (e.g., electric bill with your name and address).

2. We have asked that you bring proof of your income. Income includes pay stubs from jobs, child support/alimony, TANF, disability award letters, Social Security award letters, etc. Your income must not exceed 200% of the Continental United States poverty guidelines.

3. If you have no personal income and someone else pays all your bills, you MUST present a written signed statement from that person specifying which expenses they pay for your and how much. The income level should be sufficient to cover your monthly expenses.

All boxes of food are filled by sponsors from churches, businesses, schools, civic groups, and individuals all over the county. For this reason, the food items inside the boxes will vary. GRACE has requested that boxes be filled with items for a complete Thanksgiving meal, but cannot guarantee that the items you receive will be to your liking. Please remember that our sponsors do have a genuine interest in helping families in our community.

GRACE’s goal is to offer this assistance in hopes that you and your family will enjoy a traditional style Thanksgiving meal in the comfort of your home.

I understand the terms of this registration form and have received a copy of the above disclaimer.

CLIENT'S INITIALS:*

Use this space to upload documents such as ID, Proof of Income, Letters from others. Thank you