COVID-19 Positive? *

Please indicate if you are someone in your household is COVID-19 positive or has recently been in contact with someone that is COVID positive..

Yes

No

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Employment status *

Employed

Unemployed

Retired

Disabled

Student

Other

Race/Ethnicity *

Black

White

Asian

Hispanic or Latino

Hawaiian / Pacific Islander

Native American / Alaska Native

Multi-Racial

Other

Are you homeless? *

Yes

No

Please check all public benefit programs you are currently participating in. *

SNAP (former food stamp program)

WIC

TANF

Medicaid/Medicare

School Meals (Free & Reduced Priced Lunches)

LIEAP (energy assistance)

Section 8 (housing assistance)

CHIP (Children’s Health Insurance)

Child Care Assistance (Subsidized Daycare)

Senior Commodities

Unemployment Insurance

Social Security

Farmer’s Market Coupons

Earned Income Credit

Dietary restrictions *

None

Low salt

Low sugar

Diabetic

Lactose intolerant

Vegetarian

Pregnant

Taking certain medications

Food allergies