Application

Information Card

Please complete an Information Page. The information you provide will be kept confidential.

Print application and bring with you when you shop for the first time.

OR

Come in with a Photo ID and proof of who lives in your household.

* When you attend a class, you receive a week's worth of groceries. *

Please submit information completly below.

Name of head of household_________________________________________________________________________________________________________________

Address ____________________________________________________________________________________________________________________________________

Phone Number ________________________________________ Email __________________________________________________________________________

Income source (employment/SSI/SSD/Welfare/Other)

Amount of monthly income $_________________________________

Food stamps $_______________________________ Medicare/Medicaid ____ Housing ______ Other _____________

Members in your Household

Name Birthday Age Gender Relationship

______________________________________________________________________________________________________________________________________________

Are you interested in classes in: Budgeting Healthy Cooking Health Improvements Parenting Other ______________________________________________________________________________________________________________________________________________

Office Note:

approved by: _____________ date_____________ verified by _______________ date4__________ USDA Card.________ date _______________