Community Cupboard Intake Form
If you have been affected by COVID-19 in any way please submit this form and we will contact you within 24 hours to make an appointment to get the items you need from our Community Cupboard
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Are you currently homeless?
Yes
No
Number of Adults in Household?
How many adults currently live in your home?
Ages 18-25
Ages 26-50
Age 50+
Number of Children in Household?
How many children currently live in your home?
Ages 0-5
How many kids do you have in this age group?
Ages 6-12
How many kids do you have in this age group?
Ages 13-17
How many kids do you have in this age group?
Needs Assessment
The following section will help us determine how we can better serve you.
Have you or anyone in your household been affected by COVID-19
Yes
No
Do you have any food allergies or restrictions?
Yes
No
If yes, what foods should we avoid?
Are you in need of infant care products?
Yes
No
If yes, what's your biggest infant need?
Infant Formula
Baby Food
Pampers
What kind of baby formula do you use?
Tell us what kind of formula you use, we will try to get the closest to that.
If you need pampers, what size?
Newborn
Size 1
SIze 2
Size 3
Size 4
Size 5
What are your 4 biggest household needs at this moment?
Tissue
Paper Towels
All Purpose Cleaner
Bleach
Dish Soap
Comet
Toilet Bowl Cleaner
Soap
Band-Aids
Toothpaste
Toothbrush
Kids Toothbrush
Kids Toothpaste
Other
Are you in need of Cat or Dog Food?
Yes
No
How many Cats?
0
1
2
3
4
5+
How many cats do you currently own?
How many Dogs?
0
1
2
3
4
5+
How many dogs do you currently own?
Are you currently behind on an of the following bills?
Mortgage/Rent
Lights
Water
Gas
We partner with local agencies that can assist with these needs, do you need a referral?
Yes
No
If yes, for what Bills?
Mortgage/Rent
Lights
Water
Gas
Other
What Amount is Due?
Benefits
What benefits are you currently receiving? If none and you would like to check your eligibility, let us know below.
Do you currently receive SNAP benefits?
Yes
No
Would you like to apply for SNAP benefits?
Yes
No
Do you currently receive TANF?
Yes
No
Would you like to apply for TANF?
Yes
No
Do you currently receive Medicaid or Medicare?
Yes
No
Would you like to apply for Medicaid or Medicare?
Yes
No
Do you currently receive WIC?
Yes
No
Would you like to apply for WIC?
Yes
No
Do you need a replacement?
Birth Certificate
Social Security Card
None
Lifestyle
Let us know how you feel about the topics below. We may have programs and services that can assist you in living a healthy lifestyle.
I Enjoy Cooking
1
2
3
4
5
I Try to Eat Healthy Foods
1
2
3
4
5
I am interested in Healthy Recipes
1
2
3
4
5
I am interested in Health & Wellness
1
2
3
4
5
Would you be interested in a FREE Health & Wellness workshop?
Yes
No
Is there something we can help you with not listed above?
Submit
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