Food Share Visit Form

Is this your first visit?*

YesNo
CONTACT INFORMATION
Neighbor ID
Name*

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address*

Street Address

Apartment/Lot/Unit

CityState

Zip Code
PERSONAL INFORMATION
Birthdate*

MonthDayYear
Date
Gender
Preferred Language
Other Language
What is your race/ethnicity
Are you a Veteran
Do you have a Disability
Other race/ethnicity
HOUSEHOLD INFORMATION
# of Older Adults (50+)
# of Adults (18-49)
# of Children (0-17)
Household Size
Annual Income
Health Conditions?
Dietary Restrictions?
Do you receive any of the following benefits

CSFPSNAPLEAPTANFOAPANDABSSI
TEFAP Eligible

Yes (PA)Yes (AI)
Would you like to allow another person to pick up your box?

NoYes
ACCESS INFORMATION
How Would You Like To Receive Your Food

In-person ShoppingDrive-Thru (Pre-Made Box)Someone Will Pick Up For MeDelivered to my home
A Reservation is Not Required for In-person Shopping, Drive-Thru pick up, or if Someone will pick up for you.

If you are shopping in-person, please park in the parking lot and come inside.

If you are using the drive-thru, please pull up to the pickup line when you arrive. Our team members will come to your vehicle to check you in and bring your Pre-Made box.
Please Enter Their Neighbor ID or Full Name Here*
Neighbor ID of pick up person is required. If you do not have this please contact your pick up person and ask for thier Neighbor ID, or enter their Full Name.
Deliveries are only available for the following community members living in Otero County (we will be expanding to Crowley County soon!):
- Older adults (50+)
- People with disabilities
Why Do You Need Delivery

Mobility (Disability)Mobility (Older Adult)Temporary Transportation Barrier
If you have a temporary transportation barrier we may be able to provide a one-time delivery. One of our team members will contact you to gather more information and confirm whether we can provide delivery.
Special Notes
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Case Record Type
Should be Empty:

CONTACT INFORMATION

PERSONAL INFORMATION

HOUSEHOLD INFORMATION

ACCESS INFORMATION

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