Food Distribution Intake Form
Please provide your contact details and household information. Indicate if this is your first participation and consent to media use.
First Name
*
Last Name
*
Date
-
Month
-
Day
Year
Date
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Household Size
*
Number of Adults (over 18)
*
Number of Children (under 18)
*
Is this your first time participating?
*
Yes
No
I do hereby give United Way of Broward County their assigns, licensees, and legal representatives the irrevocable right to use my name/or any fictional name, photograph image and/or statement(s) in all forms and media and in all manners, including composite or distorted representations, for advertising, trade or any other lawful purposes, including on printed advertising and promotional material and on websites and other electronic media and I waive any right to inspect or approve the finished version(s), including written copy that may be created in connection therewith. This consent is expressly intended to release United Way of Broward County from liability. I am of legal age and have read this release and am fully familiar with its contents.
*
I consent
I do not consent
Submit
Should be Empty: