Food Assistance Application

Food Assistance Application
First and Last Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Phone Type
Type of Identification
ID/DL Number
Email
example@example.com
Gender
Ethnicity
Highest Level of Education Completed
Employment Status
Homeless
At risk of homelessness
Disabled
Veteran
Are you a New or Renewing Client?
Household Members

Please fill out the following for EACH additional family member in your household. (You must provide Proof of Residence for everyone listed)
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
First Name Last Name Date Of BirthRelation: Ethnicity: Male Female
Please upload all documents here. You will need: (1) ID for everyone 18+ (2) proof of residence for all household members. If you are unable to upload these documents, please email them to foodpantry@cedarhillshares.org.

Cancelof
I understand that by signing this form, I am giving Cedar Hill Shares permission to release information regarding me and any household members to other agencies or professionals as needed in order to better meet my needs.
Client Signature
Date

MonthDayYear
Date
Cedar Hill Shares Food Pantry l 403 Houston St, Cedar Hill, TX 75104 l P.O. Box 2694, Cedar Hill, TX 75106 l 972.293.2822 l cedarhillshares.org
Should be Empty:

Food Assistance Application

Household Members