Food Assistance Referral Form
Bridges to Health Pathways
**We are actively seeking funding to continue supporting our community. We currently have a waiting list and as additional funding becomes available, we will continue to provide food cards. **
**** ONLY ONE REFERRAL SHOULD BE SENT PER HOUSEHOLD ****
I understand that funds may not be available at the time of my referral. I agree to be placed on a waitlist until funding becomes available.
*
Please Select
Yes
No
Full Name
*
First Name / Preferred Name
Last Name
Date of Birth:
Address
City
State / Province
Postal / Zip Code
Preferred contact method?
Phone Number
E-mail
example@example.com
Are you on SNAP?
*
Please Select
Yes
No
Are you able to provide proof of SNAP?
*
Please Select
Yes
No
Household Size?
*
Please Select
1-2
2-3
3-4
5-6
6+
Are you finding it challenging to get food?
*
Please Select
Yes
No
Other
Do you currently have health insurance
*
Please Select
Yes
No
Do you have an infant in the household currently on formula?
*
Please Select
Yes
No
REFERRED BY:
First Name
Last Name
Referring agency (if applicable) :
Email
example@example.com
Referral Contact:
Please enter a valid phone number.
Verbal Consent to Participate in Bridges to Heath
Consent to Participate in Activate Care network by consenting, you agree to share information with social service partners powered by Activate Care software. Your personal information may be shared securely on the Network in accordance with privacy laws to connect you with services. This consent covers all information shared by you or by anyone that has the right to share information on your behalf. You can always limit the information you provide on Activate Care by requesting to have it removed. If you no longer want your information shared on the Network, you can email b2h@gorgehealthcouncil.org
Submit
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