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Healthy Essentials Pantry

We’re here to help those in need obtain the items they need to keep themselves, their families, and their homes clean.

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We serve residents in various areas throughout Wisconsin. Our primary focus area is Racine County east of I-94.

Healthy Essentials Pantry Application Process

In order to help you, we need your help. Please complete the INTAKE FORM (required). If you need personal, baby or home cleaning products the PRODUCT LIST will become available after the INTAKE FORM is submitted for you to complete to request these items.

Both forms can be completed online or download and returned to us (instructions are on the forms).

Download Forms

Intake Form

Client Intake Form

Please fill out the form completely so we may serve you better.

CLIENT DOCUMENTATION

 

CLIENT INFORMATION

 

Mailing Address & Phone Number

Please make sure your mailing address and phone number are entered correctly. We may be able to help by having your personal care, baby care or home cleaning products delivered to you by DoorDash.

Household Information

List everyone that lives in your home.

MILITARY STATUS

Please place an "x" in the appropriate circle *

PLEASE SELECT YOUR RACIAL CATEGORY

Please place an "x" in the appropriate circle *

PLEASE SELECT YOUR ETHNIC CATEGORY

Please place an "x" in the appropriate circle *

ARE YOU RECEIVING ANY ASSISTANCE? WHAT IS YOUR EMPLOYMENT STATUS?*

Please select ALL boxes that apply to ANY ASSISTANCE your family is receiving and your EMPLOYMENT STATUS

TOTAL ANNUAL HOUSEHOLD INCOME*

PICKUP PERSON

This section is only necessary if someone will be picking up product for you.

If you will be picking up for yourself, please leave this blank.

CLIENT ACKNOWLEDGEMENT

I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge.  

NOTE: Your answers on this form are important to help determine how to best serve you, and to obtain funding to support our programs.

All applicants MUST sign this form digitally.

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