Food Distribution Intake Form

Qualifications:

	Yes	No
Receiving SSI?
Receiving Food Stamps?
Disability?
Have you picked up food from Love Is before?
Are you interested in nutrition education?
Receiving Medicaid?
Receiving WIC?
Are you considered low-income?

Number of Seniors in the home?*
Number of Children in the home?*
Which county do you reside in? .*

HaleDallasWilcoxDaleHoustonPerryCoffee
Please select the best days you can pickup?*

MondayTuesdayWednesdayThursdayFridaySaturdaySunday
Please select the best times you can pickup.*

Early MorningsMorningsEarly AfternoonsAfternoonsEvenings
What additional services are you in need of?*

ShelterUtility AssistanceHousehold SuppliesVolunteer OpportunitiesHot mealsOther
Please upload a copy of your ID*

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Release and Acknowledgement
I, hereby, acknowledge that the information I've given above is complete and accurate. ALL INFORMATION AND DOCUMENTS SHARED WILL REMAIN PRIVATE.
Date*

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Date
Client Signature*

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Release and Acknowledgement