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 _______________