Rose Francis Foundation New Client Intake Form
Please complete this form to receive access to our services.
Date
*
-
Month
-
Day
Year
Date
Section 1: Identification of Primary Applicant
Name
*
First Name
Middle Name, Last Name
Date of Birth
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Driver's License or Birth Certificate
*
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Section 2: Demographic of Primary Applicant
Sex
*
Please Select
Female
Male
Transgender
Intersex
Non-Binary
Ethnicity
*
Please Select
Hispanic or Latino
Non Hispanic or Latino
Race
*
Please Select
Alaskan American Native American
Native Hawaiian/Pacific Islander White
Black/African American ❏ Latino/Latinx
2 or More Races
Asian
Section 3: Family Information
Family Status
*
Please Select
Single Parent with Children Under 18
Single Parent with No Children Under 18
Single Person No Children Under 18
Two Parent with Children Under 18
Two Parent with No Children Under 18
Family Size (Including Primary Applicant)
*
Please Select
1
2
3
4
5
6
7
8
9
10+
Source of Income
*
Please Select
None
Employment
Government Assistance
Please explain current state or federal assistance programs you and your family use as income
*
Total Income per Year (include all incomes of each working person in home)
*
Housing Status
*
Please Select
Housed
Unhoused
Evicted
Section 4: Others Living In Home
Adult #2 ID, Birth Certificate, or SSN
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Adult #3 ID, Birth Certificate, or SSN
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Adult #4 ID, Birth Certificate, or SSN
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Child #1 ID, Birth Certificate, or SSN
*
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Child #2 ID, Birth Certificate, or SSN
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Child #3 ID, Birth Certificate, or SSN
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Child #4 ID, Birth Certificate, or SSN
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Child #5 ID, Birth Certificate, or SSN
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Child #6 ID, Birth Certificate, or SSN
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Section 5: Desired Service
Which services will you are your family be needing
*
Food Pantry, Clothing Closet
Emergency Financial Assistance
Virtual Behavior Training
Community Resources
IMPORTANT Program Information
If your family will be using the Emergency Financial Assistance program please complete our request form on our website. If your family will be using the Online Behavior Training program please locate training available for purchase or sliding scale on our websites online store. If your family will be using the Community Resource program please contact admin@rosefrancisfoundation.org with your specific needs to be sent a community resource list within three business days.
Welcome Message
Thank you for enrolling in the Rose Francis Foundation Food Pantry. We are excited to support you and your loved ones with easier access to food in Fayetteville, North Carolina. The Food Pantry is 100% donation-based and funded by local donors and grantors around the United States. We are grateful to be able to bring this amazing program to you and your family.
How to Use the Pantry
You will receive a text/call from 910-203-1595 a week before you are eligible or pick up. Once you receive that message you will be able to schedule your pick up on our website by following this link; https://www.rosefrancisfoundation.org/book-online. Once you book your pick up date and time, you will only receive our food on that pick up date and time. Following your pick up you will be asked to complete a feedback form on your experience at this link; https://docs.google.com/forms/d/e/1FAIpQLSe17u3OWVpXwcg1FRBS5dPRZSbKpSKZ1Ot87JzlQXkeGeYvMQ/viewform?usp=sf_link
Path to Becoming a Client
To become a Client you will be required to complete all fields in this form, which includes; New Client Intake, Food Pantry Preferences, and media Release.
How it Works
Due to the donation-based nature of our Food Pantry each member in your family is allotted 4 items from each category a month per person. You are not limited to the amount of times your request picks up or delivers throughout the month, just how many items you are allotted throughout the month. Additionally, as our donation volume increases items per person will increase as well. Our categories include; Perishable, Nonperishable, Clothing, Hygiene, and Miscellaneous.
Pantry Preference Form
Welcome to Rose Francis Foundation's Pantry Preference Form. Please complete the entire form to claim your preferences. Note: All preferences will guide Food Pantry volunteers and employees in selecting your monthly order. This form is not a promise that all preferences will be met. In the event you receive an item that you do not prefer contact(803)470-4012 for a exchange.
Allergens and Accommodations
Allergens and Accommodations
*
Non Perishables
Milk
Will Accept
Allergic
1%
2%
Skim
Condensed
Almond
Oat
Cashew
Water
Will Accept
Allergic
Distilled
Spring
Sparkling
Flavored (No Sugar)
Flavored (Sugar)
Fruits
Yes
No
Allergic
Do you want fruit?
Vegetables
Yes
No
Allergic
Do you want vegetables?
Juice
Will Accept
Allergic
Apples
Orange
Grape
Cranberry
100% Juice
0% Juice
Miscellaneous
Will Accept
Allergic
Baking Items
(Flour, Sugar, Baking Soda/Powder,
Cocoa)
Muffin Mix, Pancake Mix, Brownie Mix
Vinegar, Oil
Cereal
Fruit Snacks
Pasta Noodles
Soup, Broths, Sauces, Pastes
Perishables
Will Accept
Allergic
Fish
Beef
Chicken
Turkey
Pork
Plant-based Protein
Breads
Will Accept
Allergic
White
Wheat
Rye
Sourdough
Whole Grain
Bagels, Rolls
Dairy
Will Accept
Allergic
Cheese
Eggs
Dry Infant Formula
Liquid Infant Formula
Plant-based Cheese
Hygiene
Children's Clothing
Will Accept
Diapers sz1-3
Diapers sz3-5
Diapers sz5+
Pull ups
Underwear
Bras
Bathing Items
Lotions, Butter, and Oils
Tampons, Pads, and other Menstrual Items
Clothing
Children's Clothing
Will Accept
0-3
3-6
6-12
Sm
Med
Lg
Maternity Clothing
Will Accept
Xs
Small
Med
Lg
X-lg
2XL
Signature
*
Media Release Form
Required to complete by all recipients of services. At Rose Francis Foundation, we are committed to raising awareness about the important work we do to support women and children in our community. By signing this form, you are granting permission for the organization to use photos, videos, interviews, and other Media of you or your child if applicable at the discretion of the organization to continue to uphold our organizations mission.
Consent
I, (signature below), understand these images and materials may be used in public or private media and may appear in various forms, including but not limited to, photographs, videos, social media, and promotional campaigns. I, (signature below), grant Rose Francis Foundation the right to use my image, voice, and/or story in photos, videos, audio recordings, or written content for the following purposes;
Please select all that apply
*
Promotion of the organization website, social media, and all digital platforms
Print materials such as brochures, newsletters, and annual reports
Media outreach including newspapers, radio, and television
Educational content and fundraising campaigns
Any other promotional or outreach-related activities that support the organization's mission
I do not give consent to Rose Francis Foundation to use me or my family in any Media.
Acknowledgement and Agreement
I understand that I will not receive any compensation for the use of my image, voice, or story. I acknowledge that the organization will own the rights to the materials produced and that they may be shared or publishes without approval from me. I acknowledge that my participation is voluntary, and I may withdraw my consent at anytime by contacting the organization and requesting to update my consent preferences. I understand that any Media already produced or published prior to my withdraw may still be used. I confirm that I am the legal guardian or representative of any minors who image, voice, or likeness in included in this consent.
Select One
*
I Consent
I Do Not Consent
Participant Information (Adult 1)
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Signature
*
Participant Information (Adult 2)
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
Minors Informations
Please include full name, date of birth, relationship to minor
*
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