Intake Form

Intake Form

BREATHE Care Resource Center
We are now open in our new location at 2305 Santa Clara Drive Suite F!
Our new location is just one turn from our old location. If coming from St. George, head west on Sunset Boulevard until it turns into Santa Clara Drive. After passing the library on your right, turn left into the Town Square shopping center. We are in the corner just past Dominoes.
Name*

First NameLast Name
Are you at least 18 years old?*

YesNo
We're sorry, but you must be at least 18 years old to fill out an intake form and pick up food and supplies for your family. We reserve the right to ask to see your ID upon pickup. Please have an adult in your household complete this form.

If you are under 18 and have special circumstances, such as homelessness or emancipation, please call 435-319-8404 and make an appointment to discuss your situation.
How many people are in your family?*
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
ZIP Code *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email*
example@example.com
What is your household income? (This is only for statistical purposes. We do NOT base your eligibility on income.)*

Under $15,000$15,000-$24,999$25,000-$34,999$35,000-$49,999$50,000-$74,999$75,000-$99,999$100,000-$149,999$150,000+
What resources are you in need of?*

FoodToiletriesCleaning suppliesDiapersTemporary place for your family to stay at nightHelp with budgeting and financial literacyChildcareOther
If you need diapers, which sizes are you in need of? (This is not a guarantee that we will have your needed sizes when you pick up, but it helps us priortize current needs.)

PreemieNewbornSize 1Size 2Size 3Size 4Size 5Size 6Size 72T-3T Pull-Ups3T-4T Pull-Ups4T-5T Pull-Ups5T-6T Pull-UpsOther
Which are you interested in?*

Pick up needed food & suppliesOther
How often do you generally pick up food and supplies from us?*

This is my first time.This is my 2nd time.WeeklyTwice per monthOnce per monthSporadically, as needed
How did you hear about us?*
Comments & Questions
Please note that only one adult per household should submit an intake form in a week. Our processes and policies may evolve as we find what works best.

Our current hours for pick-up are MONDAY-THURSDAY from 11:00 AM to 2:00 PM and FRIDAY from 2:00 PM to 6:00 PM.
Signature*

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Please verify that you are human*
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