Eastern Oregon Care Boxes Sign-Up Form

Program Information & Eligibility

EVEN IF YOU DON'T QUALIFY FOR SNAP/EOCCO/GOVT ASSITANCE YOU MAY STILL REQUEST A BOX DUE TO AN OVERWHELMING AMOUNT OF PEOPLE NEEDING HELP MEETING THE BASE STANDARD OF LIVING IN ALICE HOUSEHOLDS.

Completing this form does not guarantee receipt of an Eastern Oregon Care Box or that boxes will have all items requested. Boxes will be distributed based on available funding, donated supplies, program capacity, and demonstrated household need. Priority may be given to households experiencing higher levels of financial hardship, limited access to resources, food insecurity, transportation barriers, households with children or seniors, emergency situations, and other qualifying circumstances.

The anticipated first round of distribution is planned for July/August 2026. Additional rounds may occur as funding and donations allow.All information submitted through this form will remain private and will only be used for program planning, eligibility review, communication, and resource coordination purposes by the John Day/Canyon City Parks and Recreation District

Name of Person Completing Form

First NameLast Name

Phone Number (MUST have text function)

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Full Home Address (ex: 123 NW Blank St., John Day, OR 97845)

Preferred Contact Method

Monthly NET Household Income (this is different than what your gross pay would be; this is the amount of money you actually receive after taxes are taken out.)

Monthly Expenses List (it's okay if these aren't 100% accurate. Estimate when needed. List all utilities, health insurance, childcare, pet / service animal / working animal items, hygiene items, food, and anything else you feel is important to include)

Number of Adults in Household

Are there seniors (60+) in the household?

Please List Gender and Ages (example: If you have 2 adults and it's 1 man age 28 and 1 woman age 30, the gender and ages would be typed out as M28 and F30)

Number of Children in Household

If Children are Present Please List Gender and Ages (example: If you have 2 kids and it's 1 boy age 8 and 1 girl age 10, the gender and ages would be typed out as M8 and F10)

Are there Service Animals / ESA's / Working Animals / Pets in the Home? If yes, please list # and type (Ex: 2 dogs, 1 cat, etc.)

Are there household members with disabilities, medical concerns, or dietary restrictions we should consider? If yes, please explain and include how that impacts the household.

What are resources you could really use to ease the burden?

Any other resources that would be helpful that aren't listed above?

Are there any allergies or medically necessary food restrictions in your household?

Do you currently receive any assistance programs? (Optional)

How often would support boxes be helpful to your household?

How urgently does your household need assistance?

When would assistance be most helpful for your household?

Access & Delivery: Do you have reliable transportation to pick up items?

Access & Delivery: Would delivery assistance be helpful if available?

Preferred Pick-Up Time/Days

What circumstances are currently creating the greatest need for support in your household? (Check all that apply)

If comfortable sharing, please briefly explain your household’s current situation or why support would be helpful at this time. (Optional)

Would your household like to be contacted about future rounds of assistance or related community resource opportunities if additional funding becomes available?

What additional community resources or programs would you like to see offered?

Would you like information about any of the following related to JDCCPRD:

Would you be interested in volunteering or helping support this initiative in the future? Monetary OR In-Kind

Which of the following best describes your household’s current financial situation?

Has your household experienced any of the following within the last 12 months? (Check all that apply)

How often does your household struggle to afford basic necessities?

Which basic needs create the greatest financial strain for your household? (Select up to 5)

Does your household identify with any of the following barriers to accessing support services?

Is there anything else you would like us to know about your household needs or situation? (Optional)

Eastern Oregon Care Boxes Sign-Up Form

Household Information

Resource & Assistance Needs

Community Feedback & Participation

Additional ALICE & Household Stability Questions