Care Cart Application 2026

Care Cart Application 2026–2027
Service area: If you do not reside in the following counties, please do not fill out this form: Cumberland, Harnett, Johnson, Robeson, Sampson, Wayne and County.
Applicant Information
First Name
Last Name
Street Address
Apt Number
City
State
Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact
County of Residence
Household Information

Please enter 0 if no household members fall within an age group.
Number of Household Members Ages 0–12
Number of Household Members Ages 13–17
Number of Household Members Ages 18–54
Number of Household Members Ages 55+
Food Preparation
Do you have access to a microwave, stove, or other means of preparing meals?
Food Allergies
Does anyone in your household have food allergies or dietary restrictions?
If yes, please specify food allergies
Household Food Preferences

Please note that requests are not guaranteed and are dependent upon availability
Food favorites
Transportation
Do you have a vehicle available to pick up food?
Referral Source
How did you hear about our agency?
Required Documentation
One valid government-issued photo ID

Cancelof
Accepted proof of residency (Utility Bill, Lease Agreement, Bank Statement) dated within the last 30 days showing the same name and address listed on this application

Cancelof
Date of Application

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Care Cart Application 2026–2027