GoGo Groceries Application

GoGo Groceries Application

Application for home-delivered food box service via Northeast Oregon Compassion Center
Purpose: The information requested in this application is to determine eligibility for a home-delivered food box. All information is confidential and will be used only for program purposes.
Section 1: Applicant information
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email (if available)
example@example.com

Section 2: Household information
Total number of people in the household
List all household members (names and relation to applicant)
Are there any other adults living at the same address who are able to prepare meals?

Section 4: Demographic and financial information

Note: The following information helps us understand the demographics of the community we serve and to secure grant funding. Providing this information is voluntary and will not affect your eligibility for services.
Annual household income:
Veteran status (optional):
Preferred language:
Other information: Do you have any special dietary requirements or food allergies? (e.g., allergies, texture-modified food, low-sodium meals).

Section 5: Signature and consent

• I certify that the information provided in this application is accurate and complete to the best of my knowledge.• I understand that eligibility is determined by the organization's criteria, not by any specific demographic information I provide.
Signature
Should be Empty:

Section 1: Applicant information