SHOPPER INTAKE FORM
Primary Household Member
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Primary Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Primary Household Member DOB
Signature
*
BY SIGNING HERE, I HEREBY DECLARE MY ELIGIBILITY OF USDA FOODS.
Today's Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
HOUSEHOLD MEMBERS:
List all household members, including primary household member:
*
NAME
DOB
*
-
Month
-
Day
Year
Date
AGE
M
F
ARE YOU OR ANYONE IN YOUR HOUSEHOLD A VETERAN?
*
Yes
No
DO YOU RECEIVE SNAP?
*
Yes
No
DO YOU RECEIVE SUBSIDIZED HOUSING?
*
Yes
No
DO YOU RECEIVE MASSHEALTH?
*
Yes
No
DO YOU RECEIVE FUEL ASSISTANCE?
*
Yes
No
DO YOU RECEIVE WIC?
*
Yes
No
DO YOU NEED DIAPERS?
Yes
No
If Yes, What Size Diapers?
ETHNICITY:
*
Please Select
AFRICAN AMERICAN
ASIAN
CAPE VERDEAN
HISPANIC
LATINO
MIDDLE EASTERN
NATIVE AMERICAN
PACIFIC ISLANDER
PORTUGUESE
WHITE
OTHER ETHNICITY
PRIMARY LANGUAGE:
*
Please Select
ARABIC
CANTONESE
ENGLISH
HAITIAN CREOLE
FRENCH
KHMER/CAMBODIAN
MANDARIN
PORTUGESE
RUSSIAN
SPANISH
VIETNAMESE
UKRANIAN
ASL
OTHER
Submit
Submit
Should be Empty: