SNAP Response Agency Interest form

SNAP Response Agency Interest form

United Way of the Mid-South is providing this interest form for nonprofit agencies to request information about the MemphisCares SNAP Response. Please complete all fields.
Organization/Agency Name*
Organization/Agency Physical Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name*

First NameLast Name
Title/Role*
Primary Point of Contact*

First NameLast Name
Primary Point of Contact Email Address*
example@example.com
Contact Number*
Please enter a valid phone number.Format: (000) 000-0000.
Agency Type* (Select all that apply)*

Food PantryNon-Profit Service ProviderFaith-Based OrganizationEducational InstitutionOther
Service Area & Population
What Zip Codes do you serve?*
What populations does your organization primarily serve:* (Select all that apply)*

Seniors (65+)Expectant MothersVeteransPeople with DisabilitiesUnhoused Individuals and FamiliesFamilies with ChildrenStudentsOther
Does your service population include families living at or below the Federal Poverty Level and recipients of the Supplemental Nutrition Assistance Program (SNAP)?*

YesNoUnsure
Approximately what percentage of your clients are SNAP recipients? (Select One)*

Less than 25%26 - 50%51 - 75%76 - 100%N/A - We do not currently serve SNAP recipients
Approximately how many clients do you serve monthly? (Select One)*

1-250251-500501-1,0001,000+
Current Partnerships and Systems
Is your organization currently connected with the Mid-South Food Bank?

YesNoUnsure
Does your organization have access to CaseWorthy?*

YesNoUnsure
If yes, would your staff benefit from CaseWorthy training?*

Yes, we need trainingNo, we are already trainedN/A
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SNAP Response Agency Interest form

Service Area & Population

Current Partnerships and Systems