CARE Complex Monthly Grocery Giveaway
Each bag could include a mix of items such as: Beverages, Instant meals, Baking goods, Rice & pasta, Chips, snacks, pretzels, crackers, Microwave meals, Spreads & sauces, Canned goods (variety)
👉 Please note:
The bags are pre-packed and you will not be able to select individual items.
Contents may vary from bag to bag.
Distribution will be on a first come, first serve basis.
Bags must be picked up from the CARE Complex facility.
The scheduled pickup dates will be communicated to you directly once confirmed.
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Select your gender
*
Male
Female
Intersex
Date of Birth
*
 -
Month
 -
Day
Year
Date
What is your ethnicity?
*
White
African American
Asian
Hispanic or Latino
Native American
Other
Which primary language do you use?
*
Please Select
English
Spanish
German
Russian
Korean
Tagalog
Filipino
Arabic
French
Chinese
Hindi
Vietnamese
Portugese
Urdu
Others
Do you have insurance?
*
Yes
No
If yes, indicate the type.
Medicaid
Medicare
Private Insurance
Other
Name of the Insurance Proviver
Do you receive any additional forms of income or benefits?
*
Yes
No
If yes, check all that apply.
SNAP
SSI/SSDI
Unemployment Benefits
Disability Benefits
Child Support
Other
How many people are in your household?
*
Do you have children?
*
Yes
No
If yes, please please fill in the table below.
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Name
Age
Kid 1
Kid 2
Kid 3
Kid 4
Kid 5
Kid 6
Kid 7
Are you currently employed?
*
Yes
No
If unemployed, how long have you been unemployed for? (in months)
Please fill in the following employment history. (If unemployed write the most recent job)
*
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Job Position
Employer Name
Hours per week
Current Job
Last Job
I understand that grocery bags are distributed on a first come, first serve basis, that contents may vary, and I cannot select individual items. I confirm my interest and agree to pick up my bag at CARE Complex on the communicated dates.
*
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