English: Trinity Jubilee Center Food Pantry Signup 2024-2025

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Welcome! Thank you for filling out your Food Pantry intake form online!Everyone needs to re-enroll by July 1. Thank you for getting your re-enrollment done early!
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What is your name?* This field is required.
First Name
Last Name
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What is your email address?* This field is required.We will send you a link to reopen your form in case you need to correct any info later.
example@example.com
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What is your birthdate?* This field is required.
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What is your race?Please choose one
White
Black or African American
Asian
American Indian/Alaska Native
Native Hawaiian / Other Pacific Islander
American Indian / Alaskan Native & White
Asian and White
Black / African American & White
American Indian / Alaskan Native & Black / African American
Other
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What is your ethnicity?* This field is required.Choose one:
Hispanic
Non-Hispanic
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What is your gender?* This field is required.
Female
Male
Non binary
Other
Prefer not to respond
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How many total people are in your household, including yourself?* This field is required.
Please Select
Please Select
1
2
3
4
5
6
7
8
9
10
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Person #2 Name and Birthdate
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Person #3 Name and Birthdate
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Person #4 Name and Birthdate
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Person #5 Name and Birthdate
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Person #6 Name and Birthdate
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Person #7 Name and Birthdate
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Person #8 Name and Birthdate
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Person #9 Name and Birthdate
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Person #10 Name and Birthdate
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What is the address where you live? Please include your town and your apartment number!* This field is required.
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Is anyone in your household a US military veteran or active-duty serviceman?* This field is required.
Yes
No
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Thank you for your service! What is their name?
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Have you recently received any of the following assistance from the Trinity Jubilee Center?We provide assistance with all of these things as well as resume-writing and job applications! The medical clinic is open 8:30-10:30 on Thursdays and all other services are offered starting at 11:00 today and on other days from 8:00-3:00.
Using the phone, fax, or printer
Housing paperwork
Childcare paperwork
Seeing the doctor
Connecting with other programs (including caseworker referrals and information on other programs)
Receiving mail
Other
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What other assistance did you receive?
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Does someone in your household work?* This field is required.
Yes
No
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If not, why not?
Retired
Disability or illness
No work permit
Currently applying for jobs
Not working
Other
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Other:
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Do you have transportation to the grocery store?* This field is required.
Yes
No
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Think about all of the fresh fruits and vegetables you ate over the past month. Did the majority of them come from Trinity's food pantry?* This field is required.
Yes
No
N/A New to the food pantry
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Do you come to our 11:00 Soup Kitchen to receive meals or other food?* This field is required.
YESNO
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How many days per week do you come to the Soup Kitchen?
Please Select
Please Select
1
2
3
4
5
6
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Do you eat healthier because of the Soup Kitchen?
Yes
No
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Is this your primary source of hot meals?
Yes
No
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Client Information Tracking Sheet: Lewiston-Auburn Metropolitan Statistical Area – 2023The City of Lewiston-Auburn has been awarded Community Development Block Grant (CDBG) funds from the U.S. Department of Housing and Urban Development. The proposed activity/ies are: Food Pantry and Diaper Bank. For the proposed activity/ties, the CDBG program requires documentation of program benefit. Therefore, Trinity Jubilee Center is surveying the potential beneficiaries ensuring compliance with CDBG program regulations. Your response to the following questions is critical for meeting CDBG program requirements. All responses are confidential and used solely for securing CDBG grant funds. THIS INFORMATION WILL BE KEPT CONFIDENTIAL.
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Based on the previous "Client Information Tracking Sheet: Lewiston-Auburn Metropolitan Statistical Area – 2023" chart, please select your income limit:* This field is required.
Extremely low
Low
Moderate
Over 80% MFI
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Do you live in Lewiston?* This field is required.
Yes
No
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I certify that all information provided is accurate.* This field is required.Signature:
Clear
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Date
Date
Year
Month
Day
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Please upload proof of your address. This can be a bill, a lease, a DHHS statement, or other official mail. It must be less than 2 months old.If you do not have it available right now you can upload it later. Your application will be incomplete until this proof is received.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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If you would like to enroll in our Diaper Bank, please upload proof of your child's name and birthdate. This can be a birth certificate, Mainecare card, passport, or other official document. We provide diapers to children under 48 months.If you do not have it available right now you can upload it later. You must provide this proof before receiving diapers.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Signature:* This field is required.By my signature below, I release the Trinity Jubilee Center and the original donor from any liability or harm (including injury or death) or losses in connection with the food or supplies I have received. I assume any risks and covenant not to sue the released parties with respect to such harm or losses. I understand that the Trinity Jubilee Center operates on limited funds and in support of others, and I will only request and take items that I reasonably expect myself and/or my family to use. My household will not receive food from the Trinity Jubilee Center’s food pantry more than once per week.
Clear
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Do you have feedback for us?We know the Food Pantry is busy and there's not a lot of time to talk! We would love to hear from you! What could we do to make the Food Pantry better?
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