Thrivability Eligibility

SECOM Healthy Food Pantry is excited to provide home delivery of food and hygiene items. Please complete this application to be considered for home delivery. Applications will be processed on a first come, first serve basis. If you need asisstance completing this application, please email pantrymanager@secomresourcecenter.org
Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Phone Number*
Will someone at your residence be available to receive your food at your front door at a scheduled time on the first thursday of every month?*

YESNO

Household information
How many people are in your household? (This includes anyone who lives in your house such as friends, family, and others.)*
What is your households approximate monthly income? (employment, SSI, child support, etc.)*
Please list the names and dates of birth of every person in your household below.
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date
Name

First NameLast Name
Date of birth

MonthDayYear
Date

Agreements
By signing below, I agree to the following statements:
1. I agree that someone at my residence will be available to receive my food at my front door within 15 minutes of my scheduled delivery time. If no one is available to accept my food, I will contact SECOM at least 24 hours in advance. If I repeatedly miss my delivery time, I will lose my place in the delivery program.
2. I agree to notify SECOM if my disability status changes and I am able to come to the Food Pantry in-person.
3. I agree to reapply for delivery in March 2025. This application will be used for the 2024 program year only. I understand that applications will be processed on first come, first serve basis. I understand that SECOM cannot gaurentee my place in the 2025 program year.
4. I agree that SECOM staff and volunteers may have access to the information in this application when relevant. No one outside of SECOM staff and volunteers will have access to my information.
Firma*

Powered by Jotform SignClear
Should be Empty:

Applicant Information