September 2023 Food Distribution Request Form

September 2023 Food Box Distribution: Midwest Food Bank Food Box. Thursday 9/28 from 12 pm - 2 pm

*Deadline to register is the Wednesday before the event at 12 pm. You must hit SUBMIT Button for your registration to go through*
ASA Now is proud to provide monthly food boxes. This is a powerful way to help children feel safe and cared for and helped to offset the grocery bill for caregivers.

Whether funds are tight or this brings the opportunity to help caregivers take the children in their care to a special event or to purchase an item they typically would not purchase for themselves, our mission is to be here to support our village.

🌟 MONTHLY FOOD BOX DISTRIBUTION 🌟

🗓️ When: September 28, 2023

⏰ Time: 12 PM – 2 PM

📍 Location: ASA Now - Jacob's Mission Community Center

🏠 Address: 7830 E. University Dr. Mesa, AZ 85207

✨ Who can participate: This event is for Kinship Caregivers, Licensed Foster Caregivers, Foster/Adoptive Caregivers, Guardianship Caregivers for children who previously were or are under the custody of Arizona Department of Child Safety (DCS) and Group Homes.

🚨 Registration Deadline: Wednesday before the event @ Noon. If you are in need of a food box and miss the registration deadline, please call 623-428-1592 for assistance.

✨ Come prepared with a cooler or cooler bag to put frozen or refrigerated food into. We will not know exactly what we are getting until we pick items up, but we typically receive shelf stable foods, bread, produce, refrigerated, and frozen items.

For questions, call (623) 428-1592 or email Volunteer@ASANow.org

⚠️ Cancellations: We understand that emergencies happen. If you are unable to pick up your food, please send someone in your place and let us know who will be coming.

If you are unable to attend and cannot make arrangements for someone to pick up for you, you MUST notify us ahead of scheduled pick-up time and we ask that you give us as much notice as possible by calling 623-428-1592. Be sure to leave a voicemail or text if we don't answer. Failing to pick up your food box or not notifying us ahead of time will exclude you from future food box events for 60 days.

✨ Feedback: Our donors and volunteers love feedback. If ASA Now has blessed your life, please take a minute to leave a positive review on Google and/or on our or our ASA Now Facebook Page or email us at Hope@asanow.org with your testimonial.

For a list of our upcoming events, check out our Events tab on Facebook or visit our website at www.asanow.org.

With Gratitude,

Angela Teachout

Susan Woodruff

Anika Robinson

'Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has". Margaret Mead

*Be sure to CONSENT, SIGN & hit the SUBMIT button*
Pick Up Location (select one)*

Mesa
Click on date(s) you are registering for (click all that apply):

Thurs September 28th
Caregiver, Parent or Aged Out Youth Name #1*

Last NameFirst Name
Caregiver or Parent Name #2 (type N/A if there is not a 2nd caregiver or parent in the home):*

Last NameFirst Name
Name of Group Home (type N/A if you are not a group home)*
Contact Number (must be a cell phone to receive text reminder)*

Area CodePhone Number
E-mail*
Address*

Street Address

CityPostal/Zip Code

COUNTY
Are you:*

Unlicensed Kinship CaregiverLicensed Kinship CaregiverLicensed Foster CaregiverTribal Foster CaregiverCaregiver with Guardianship to Child with Child Welfare InvolvementCaregiver with Guardianship not involving DCS/ Child WelfareAged Out YouthLicensed Group HomeAdoptive HomeOther
Total Number of People Living in the Home*

12345678910Other
Total Number of Adults Living in the Home (including children over 18 who are no longer in high school)*

12345678910Other
Total Number of Children Living in the Home (including children over 18 who are still in high school)*

12345678910Other
Number of Children in Foster Care, Tribal Foster Care, or DCS Guardianship Living in the Home (including those 18 and over who are still in high school):*

012345678910Other
Number of Adopted Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
Number of Biological Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
Number of NON-DCS Kinship or NON-DCS Guardianship Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
We are required to gather data about the children, youth, and families we serve. The next question will ask if your family falls below following income levels based on household size:

1 person: $20,385

2 people: $27,465

3 people: $34,545

4 people: $41,625

5 people: $48,705

6 people: $55,785

7 people: $68,865

8 people: $69,945

Add $4270 per additional household member
Based on family size, does your family fall below the income level shown above? (Group homes, please click yes)*

YesNoOther
I Need Help or Assistance With the Following (Check All That Apply)

Basic Necessities (clothes, underwear, hygiene kits, etc)Emergency Essentials Food Box (Mesa location only)First Aid Kit (Mesa location only)Support GroupTraining/ Workshops for Caregivers and Youth ages 14-18Housing for Aged Out YouthK-12th grade Tutoring, Dance, Karate, Art, Cooking, Piano, Guitar, Musical Theater, Yoga (Mesa location only)
As a foster care nonprofit organization, we must obtain certain information from the families we serve. If you are caring for a child or youth with child welfare involvement, we must collect their Notice to Provider information.

If you have been served by ASA Now and you have uploaded their Notice to Provider information for any of our events in the current year, you may skip the questions below.

If you have never upoloaded their Notice to Provider, this information and/or if they are a new placement in your household, please fill out the form for EACH Eligible DCS Guardianship, Child in Foster Care or Aged Out Youth in order of youngest to oldest.
Have you provided information in the current year for each child in your home who is: in foster care, tribal foster care, DCS guardianship, or Aged Out Youth?*

All foster/tribal foster/DCS guardianship/aged out youth in my home have been served by ASA Now in the current year and I have provided information and uploaded their Notice to Provider (NTP) for a previous event.My family has NOT been served by ASA Now in the current year so I have not provided information (NTP) for my foster/tribal foster/DCS guardianship/aged out youthI have a new placement whose information I need to provideI do not currently have any children who are foster/tribal foster/DCS guardianship/aged out youth in my home. I only have foster/adopted children living in my home.

Acknowledgement
PARTICIPANT AGREEMENT, RELEASE, WAIVER, AND ASSUMPTION OF RISK - Click HERE to view waiver.

Neither ASA Now, nor the donors of the products to ASA Now, warrants or guarantees these products in any way. I understand I am using them at my own risk.

I agree that I will not barter, trade, or sell any goods received by ASA Now.
I have reviewed, understand, and agree to comply with the above terms*

I agree
ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19 - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
GRANT OF RIGHT TO USE LIKENESS - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
I acknowledge that I have read the above waivers and release, understand that I have given up substantial rights by signing it, and sign it voluntarily, without any duress or undue influence.*

I agree
Is There Anything Else We Can Help You With?

YesNo
Describe Any Additional Needs
Signature*

Clear
Should be Empty:

September 2023 Food Box Distribution: Midwest Food Bank Food Box. Thursday 9/28 from 12 pm - 2 pm