AmPowering's Feed The Need Program Registration Form

AmPowering's Feed The Need Program
AmPowering (www.ampowering.org)

We are a 501(c)(3) non-profit agency, AmPowering (EIN #82-1392485 ), dedicated to reaching out to communities in need of food and other assistance through our FeedTheNeed & Mayka (My Mother's Home) program. Despite the existence of many food banks, there are still significant gaps in food assistance that leave many individuals and families struggling. Our goal is to fill these gaps and ensure that no one goes hungry and everyone has shelter. If you are in need of these resources, please submit the form to receive assistance.
I want assistance*

GroceryHousehold cleaning suppliesPersonal hygiene itemsDiapersRental assistanceInterim shelter if you are facing homelessness. We need explanation about your situation. (Please note we provide interim shelter in hotels, but you need to have a credit card for incidentals, as we pay only for hotel room nights. Also if you have service animals, you need to pay for them)Other
Please explain your current situation and why you need help from us? (Please also mention the name of the organization or care team who referred you to AmPowering)*
Gender*

MaleFemaleTransgenderDon't Prefer to answer
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of birth*

MonthDayYear
Date of birth
Number of people in the family*
Number of people in each age category:
Age 0-17
Age 18-24
Age 25- 34
Age 35-44
Age 45-54
Age 55-64
Age 65-74
Age 65-74
Ethnicity*

WhiteAsianAmerican IndianBlack or African AmericanMiddle Eastern or North AfricanHispanic Latino or Spanish OriginNative Hawaiian or Other Pacific IslanderOther
Education*

Less than HS DiplomaHigh SchoolSome CollegeBachelors DegreeGraduate DegreeHigher Education
Employment*

StudentUnemployedSelf-employedPart-time employmentFull-time employment
Household Income*

$0 - $24,999$25,000 - $49,999$50,000 - $74,999$75,000 and above
Marital Status*

SingleMarriedDivorcedWidowed
Languages spoken*
Do you have any disability*

YesNo
Type of disability
Should be Empty:

AmPowering's Feed The Need Program

AmPowering (www.ampowering.org)