Mobile Pantry Registration - Period Supplies

Mobile Pantry Registration - Period Supplies

Distribution Policy & Intake Form
Registration is required at least 24 hours prior to your first visit to any mobile pantry distribution day. On-site and/or same-day registration is not available. If you are not on our registration list when you arrive at a distribution, we will be unable to give you products.

Individuals and families can visit our mobile pantry once a month. Our program is not designed to be the sole source of support for an individual or family, but rather to supplement what they can provide for themselves. We strive to assist our community members in their journey to self-sufficiency.

Period supplies are only distributed on the designated mobile distribution days. The distribution schedule, including dates, times, and locations, can be found on our website at https://www.keepingfamiliescovered.org/get-help.

Photo ID is required for the individual/guardian/caregiver at every visit (driver's license, state ID, school ID, military ID, passport, VISA) to a mobile distribution.
Contact Information
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail*
example@example.com
How did you hear about us?*
Please Specify*
Date of Birth:*
Gender:*

MaleFemale
Marital Status:*

SingleMarriedDivorcedSeparatedWidow
Race:*

American Indian or Alaska NativeAsianBlack or African AmericanHispanic / LatinoNative Hawaiian or Other Pacific IslanderWhiteOther
Do you have insurance?*

MedicareMedicaidHMOPPOOtherNone
Are you receiving help with period supplies from other agencies?*

YesNo
If yes, which agencies? Please list them. If none, please type N/A.*
What is your relationship to the person completing this registration form?*

SelfParentGrandparentLegal GuardianCaregiverFamily MemberOther
Demographic Information
What types of period supplies do you typically need and purchase?*

PadsTamponsLinersOther
Are you in need of other products to manage your period? Select all that apply.*

Feminine WipesPain Relief Medications (Tylenol, Advil, etc.)None
How many adults are in your household?*
How many adults in your household currently work outside of the home?*
What is the total annual income for your household?*
How many adults in your household are currently looking for work?*
How many adults in your household are students?*
Are you a veteran or military family?*

YesNo
Is anyone in your household eligible for WIC, SNAP, TANF, or food stamps?*

YesNo
In the past year, have you had to make a choice between buying period supplies and buying something else you/your family needed?*

YesNo
Receiving period supplies will allow me and/or my family to (check all that apply):*

Send a child to daycare or other programsReduce my stressLook for workMake my child happierGo to workBuy foodHelp my child to be healthierGo to school or job trainingPay a billBuy clothingBuy non-food items like toothpaste, soap, or toilet paperStay clean, dry, and healthyHave a better quality of lifeAvoid being homeboundParticipate in daily life and other activities/events
Would you like information about additional community resources that might be available to you?*

YesNo
Keeping Families Covered reserves the right to refuse service to an individual and/or family if they do not adhere to the program guidelines as outlined, or if any information submitted on this form is found to be false or inaccurate. Incomplete forms, and forms that are missing the required uploaded documentation, will not be accepted.
I have read and agree to the period supplies distribution policy as outlined above.*

YesNo
I understand that the products I receive from Keeping Families Covered are donated and cannot be sold.*

YesNo
I understand that if I attempt to sell the products that are donated to me by Keeping Families Covered via Facebook marketplace or any other way, I will no longer be eligible for service.*

YesNo
Type your full name: *
Type your initials:*
Date:*

MonthDayYear
Date
Should be Empty:

Mobile Pantry Registration - Period Supplies

Demographic Information