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.
Phone Type*
Type of Identification*
ID/DL Number*
Email
example@example.com
Gender*

MaleFemale
Ethnicity*
Highest Level of Education Completed

College GraduateTrade/Tech SchoolSome CollegeHigh School/GEDSome High SchoolNo High School
Employment Status

Full TimePart TimeUnemployed
Homeless

YesNo
At risk of homelessness

YesNo
Disabled

YesNo
Veteran

YesNo
Are you a New or Renewing Client?*

NewRenewing
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*

Clear
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