Devoted to advancing the lives of others

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 and healthy.

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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 and the PRODUCT LIST. The Product List will become available after the Intake Form is submitted.

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


Download Forms


Intake Form (English Only)

Client Intake Form

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

CLIENT DOCUMENTATION

 

How did you hear about Giving to the Nations?

 Please answer the 5 questions below.


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 choose one *


PLEASE SELECT YOUR RACIAL CATEGORY

Please choose one *


PLEASE SELECT YOUR ETHNIC CATEGORY

Please choose one *


ARE YOU RECEIVING ANY ASSISTANCE?*

Please select ALL boxes that apply to ANY ASSISTANCE your family is receiving.


EMPLOYMENT STATUS*


TOTAL ANNUAL HOUSEHOLD INCOME*


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.

IMPORTANT - Another Required Form

After you submit this form, the PRODUCT LIST will become available for you to complete. 

The Product List tells us what cleaning products for personal care, baby care, or your home you are in need of.

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