The Market Place Nutrition Program Eligibility Form

1

Your Full Legal Name* This field is required.

First Name

Last Name

2

Phone Number* This field is required.PROVIDE THE NUMBER YOU WOULD LIKE TO RECEIVE DELIVERY CONFIRMATIONS TO. DO NOT PUT HOUSE PHONE NUMBER.

Please enter a valid phone number.

3

Email* This field is required.

example@example.com

4

Do you have Medicaid?* This field is required.

YESNO

5

Full Name Of Head of Household (HOH) or Primary Applicant* This field is required.

6

What is your CIN? (Client ID Number)* This field is required.A mix of 8 numbers and letters.

7

Household Members' Names, CIN (Client ID Number) and Date of Birth* This field is required.Must include ALL household full names, CIN and date of birth + specify next to their name their condition. Without condition they do NOT qualify!

8

Full Address* This field is required.MUST INCLUDE APARTMENT NUMBER IF ANY, ONLY PUT ADDRESS ON FILE AT MEDICAID OR CASE WILL GET REJECTED FOR ADDRESS MISMATCH.

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

Are you or someone in your household pregnant?* This field is required.IF ANSWER IS YES PUT DUE DATE INSIDE THE HOUSEHOLD INFO NEXT TO YOUR NAME

YESNO

10

Did you have a child in the last 12 months?* This field is required.

YESNO

11

Did you recently go through a miscarriage?* This field is required.WITHIN 1 YEAR

YESNO

12

Do you have a child that receives Special Needs Services?* This field is required.IF ANSWER IS YES YOU MUST SPECIFY WHAT SERVICE AND WHICH CHILD RECEIVES THE SERVICES IN THE HOUSEHOLD INFORMATION BOX

YESNO

13

Is anyone chronically ill?* This field is required.IF THE ANSWER IS YES YOU MUST SPECIFY WHO HAS A MEDICAL CONDITION AND WHAT IT IS INCLUDING MEDICATIONS INSIDE THE HOUSEHOLD INFORMATION BOX

YESNO

14

If eligible, do you prefer to receive raw groceries or prepared foods?* This field is required.You cannot receive both, its either or. *Prepared Foods by House of Glatt

Raw GroceriesPrepared Foods*

15

Are you currently enrolled in the program under a different agency? * This field is required.

YES*NO

16

If you answered YES, please specify which agency and reason for transfer requestIF YOUR ANSWER IS YES FOLLOW THE STEPS IN THE AUTO RESPONSE EMAIL HOW TO CLOSE OR TRANSFER YOUR CASE