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From Your Father Application
This short form makes it simple to apply and join our family.
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2
Have you applied before?
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NO
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3
Which county do you live in?
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Davidson
Rutherford
Montgomery * Limited Availability*
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Do you have access to a car?
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5
If not, what is your means of transportation at this time?
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Do you need to request a delivery waiver?
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*Documentation will be requested for waiver request*
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Please explain why you need approval for a delivery.
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8
Do any of these descriptions apply to you?
*
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Single
-
parent
families are families with children under age 18 headed by a
parent
who is widowed or divorced and not remarried, or by a
parent
who has never married.
SINGLE PARENT IN NEED OF ASSISTANCE
SEVERE MEDICAL DISABILITY
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9
On a scale of 1-5 how supported do you feel as a single mother right now?
*
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1
2
3
4
5
1
2
3
4
5
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10
Please explain your situation.
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11
Which best applies to what you are looking for?
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I want a change in my life. I am willing to attend workshops and do whatever it takes
I want to receive the resources I need but do not want to attend workshops at this time.
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12
Which program are you applying for?
Please Select
Essentials Program
Reknewal Program
Please Select
Please Select
Essentials Program
Reknewal Program
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13
Name
*
This field is required.
First Name
Last Name
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14
Address
*
This field is required.
If you do not have a permanent address please provide information for where you receive mail. This is the place we will deliver your box.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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15
Phone Number
*
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Area Code
Phone Number
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16
Email
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example@example.com
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17
DOB
*
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What is your date of birth?
-
Date
Year
Month
Day
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18
Gender
*
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Female
Male
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19
ETHNICITY
*
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White
Black/African American
Hispanic
Middle Eastern
Other
White
Black/African American
Hispanic
Middle Eastern
Other
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20
What size is your household?
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This includes you and your children under 18
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21
Do you have pets?
*
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Please know that we require all animals to be put away when our volunteers are delivering your box.
YES
NO
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22
Education
*
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College
Highschool-Incomplete
Highschool/GED
College
Highschool-Incomplete
Highschool/GED
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Marital Status
*
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Divorced
Married
Single - No spouse in home (not married)
Single - Spouse in home (not married)
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Other
*
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At Risk Of Being Homeless
Disabled
Homeless
None
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25
If an emergency came up today, do you have at least 1,000 cash available?
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NO
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26
Employment.
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Full Time
Part-Time
Disabled
Student
Unemployed
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27
Government Benefits
*
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This question does not affect your application. We understand that even this assistance is sometimes not enough.
Receives Food Stamps
Receives Medicaid
Receives Medicare
Receives Social Security
Receives Veterans Benefits
Receives WIC
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28
Child 1 Information
*
This field is required.
* We like to add additional items when we have them available
Name
Birthday
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Female
Male
Please Select
Please Select
Female
Male
Gender
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Child 2 Information
* We like to add additional items when we have them available
Name
Birthday
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Male
Please Select
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Child 3 Information
* We like to add additional items when we have them available
Name
Birthday
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Female
Male
Please Select
Please Select
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Gender
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31
Child 4 Information
* We like to add additional items when we have them available
Name
Birthday
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Female
Male
Please Select
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32
Child 5 Information
* We like to add additional items when we have them available
Name
Birthday
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Male
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33
Child 6 Information
* We like to add additional items when we have them available
Name
Birthday
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Please Select
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Child 7 Information
* We like to add additional items when we have them available
Name
Birthday
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Please Select
Please Select
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Child 8 Information
* We like to add additional items when we have them available
Name
Birthday
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Female
Male
Please Select
Please Select
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36
Child 9 Information
* We like to add additional items when we have them available
Name
Birthday
Please Select
Female
Male
Please Select
Please Select
Female
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Gender
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37
Are you the guardian of these children?
*
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YES
NO
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38
How were you referred?
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39
Any Food Allergies? Please List Them Below
*
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40
Are You Or Your Children On A Special Diet? If So Please Explain In 2-4 Sentences.
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How Often Are You Able To Feed Your Children Fresh And Organic Produce?
*
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Every Night
Weekly
Bi-Weekly
Monthly
None
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42
We need to make sure it's really you. Please upload your photo ID
*
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This information is private and protected.
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Please upload proof of guardianship for all children.
*
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Example : Birth Certificate, Social Security Card, or Shot Record
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Please upload proof of residence/lease agreement.
*
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45
You agree that all your answers are true to the best of your knowledge.
*
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To the fullest extent permitted by law, I hereby release and forever discharge, and agree to indemnify and hold harmless From Your Father Inc. its officers, agents, employees, and volunteers from and against any and all liabilities, claims, demands, or causes of action of any kind on account of any loss, damage, illness or injury to person or property in any way arising out of correlating to my application from assistance and/or related activities, whether due to negligence, mistake or other action or in action of From Your Father or any person or entity acting on its behalf.
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