2025 Food Distribution Request Form

Food Box Distribution: Midwest Food Bank Food Box.

Please select your food box pick up date and time and note that multiple dates can be selected.
🌟FOOD BOX DISTRIBUTION🌟

Food Distribution for Families Impacted by Foster Care Presented by ASA Now.

🗓️ When: Thursday Jan 30th, 2025

⏰ Time: 12 PM – 2 PM

📍 Location: ASA Now - Jacob's Mission Community Center

🏠 Address: 7830 E. University Dr. Mesa, AZ 85207

✨ Who can Participate: DCS Kinship Caregivers, Licensed Foster Caregivers, Foster/Adoptive Caregivers, Guardianship Caregivers for children who previously were or are under the custody of Arizona Department of Child Safety (DCS) and aged out youth up to age 21 with proof of previous or current child welfare involvement.

🚨 Registration Deadline: Registration closes at noon the day before food distribution. If you are in need of a food box and miss the registration deadline, please call 623-428-1592 for assistance.

For questions, call (623) 428-1592 or email events@asanow.org

🤝 Driving and Pick-Up Instructions: We are located on University between Sossaman Rd. and 80th St. on the north side of the street. Parking lot entrance is immediately east of the fire station and our building is set back off of the road. Please drive straight towards the back of the building and around the back of the building to the door on the west end. Your food box will be placed in your trunk by our angel volunteers.

Come prepared with a cooler or cooler bag to put frozen or refrigerated food into. We will not know exactly what we are getting until we pick items up, but we typically receive shelf stable foods, bread, produce, refrigerated, and frozen items.

⚠️ Cancellations: We understand that emergencies happen. If you are unable to pick up your food, please send someone in your place and let us know who will be coming.

If you are unable to attend and cannot make arrangements for someone to pick up for you, you MUST notify us ahead of scheduled pick-up time and we ask that you give us as much notice as possible by calling 623-428-1592. Be sure to leave a voicemail or text if we don't answer. Failing to pick up your food box or not notifying us ahead of time will exclude you from attending future food distribution events for 60 days.

✨ Feedback: Our donors and volunteers love feedback. If ASA Now has blessed your life, please take a minute to leave a positive review on Google and/or on our or our ASA Now Facebook Page or email us at Hope@asanow.org with your testimonial.

For a list of our upcoming events, check out our Events tab on Facebook or visit our website at www.asanow.org.

With Gratitude,

Angela Teachout

Susan Woodruff

Anika Robinson

'Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has". Margaret Mead
Caregiver, Parent or Aged Out Youth Name #1*

Last NameFirst Name
Caregiver or Parent Name #2 (type N/A if there is not a 2nd caregiver or parent in the home):*

Last NameFirst Name
Name of Group Home (type N/A if you are not a group home)*
Contact Number (must be a cell phone to receive text reminder)*

Area CodePhone Number
E-mail*
Address*

Street Address

CityPostal/Zip Code

COUNTY
Date of Food pick up*

Thurs Jan 30th, 2025
Are you:*

Unlicensed Kinship CaregiverLicensed Kinship CaregiverLicensed Foster CaregiverTribal Foster CaregiverCaregiver with Guardianship to Child with DCS/ Child Welfare InvolvementCaregiver with Guardianship not involving DCS/ Child WelfareAged Out YouthLicensed Group HomeAdoptive HomeOther
Total Number of People Living in the Home*

12345678910Other
Total Number of Adults Living in the Home (including children over 18 who are no longer in high school)*

12345678910Other
Total Number of Children Living in the Home (including children over 18 who are still in high school)*

12345678910Other
Number of Children in Foster Care, Tribal Foster Care, or DCS Guardianship Living in the Home (including those 18 and over who are still in high school):*

012345678910Other
Number of Adopted Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
Number of Biological Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
Number of NON-DCS Kinship or NON-DCS Guardianship Children Living in the Home (including children 18 and over who are still in high school):*

012345678910Other
We are required to gather data about the children, youth, and families we serve. The next question will ask if your family falls below following income levels based on household size:

1 person: $22,590

2 people: $30,660

3 people: $38,730

4 people: $46,800

5 people: $54,870

6 people: $62,940

7 people: $71,010

8 people: $79,080

9 people: $87,150

10 people: $95,220

11 people: $103,290

12 people: $111,360

12 people: $119,430

14 people: $127,500
Based on family size, does your family fall below the income level shown above? (Group homes, please click yes)*

YesNo
I Need Help or Assistance With the Following (Check All That Apply)

Basic Necessities (clothes, underwear, hygiene kits, etc)Emergency Essentials Food Box (Mesa location only)First Aid Kit (Mesa location only)Support GroupTraining/ Workshops for Caregivers and Youth ages 14-18Housing for Aged Out YouthK-12th grade Tutoring, Dance, Karate, Art, Cooking, Piano, Guitar, Musical Theater, Yoga (Mesa location only)
As a foster care nonprofit organization, we must obtain certain information from the families we serve. If you are caring for a child or youth with child welfare involvement, we must collect their Notice to Provider information.

If you have been served by ASA Now and you have uploaded their Notice to Provider information for any of our events in the current year, you may skip the questions below.

If you have never upoloaded their Notice to Provider, this information and/or if they are a new placement in your household, please fill out the form for EACH Eligible DCS Guardianship, Child in Foster Care or Aged Out Youth in order of youngest to oldest.
Have you provided information in the current year for each child in your home who is: in foster care, tribal foster care, DCS guardianship, or Aged Out Youth?*

All foster/tribal foster/DCS guardianship/aged out youth in my home have been served by ASA Now in the current year and I have provided information and uploaded their Notice to Provider (NTP) for a previous event.My family has NOT been served by ASA Now in the current year so I have not provided information (NTP) for my foster/tribal foster/DCS guardianship/aged out youthI have a new placement whose information I need to provideI do not currently have any children who are foster/tribal foster/DCS guardianship/aged out youth in my home. I only have foster/adopted children living in my home.

Acknowledgement
PARTICIPANT AGREEMENT, RELEASE, WAIVER, AND ASSUMPTION OF RISK - Click HERE to view waiver.

Neither ASA Now, nor the donors of the products to ASA Now, warrants or guarantees these products in any way. I understand I am using them at my own risk.

I agree that I will not barter, trade, or sell any goods received by ASA Now.
I have reviewed, understand, and agree to comply with the above terms*

I agree
GRANT OF RIGHT TO USE LIKENESS - Click HERE to view waiver.
I have reviewed, understand, and agree to comply with the above terms*

I agree
I acknowledge that I have read the above waivers and release, understand that I have given up substantial rights by signing it, and sign it voluntarily, without any duress or undue influence.*

I agree
Is There Anything Else We Can Help You With?

YesNo
Describe Any Additional Needs
Signature*

Clear
Should be Empty:

Food Box Distribution: Midwest Food Bank Food Box.