Giving to the Nations  –  devoted to advancing the lives of others

Giving to the Nations  -  devoted to advancing the lives of others

Giving to the Nations

Healthy Essentials Pantry

Intake Form

In order to help you with the products you need, please complete the Intake Form. This form is required.

You can complete the online INTAKE FORM below or download and return it to us (instructions are on the form).

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.

Download: Intake Form

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

CLIENT DOCUMENTATION

 

CLIENT INFORMATION

 

Household Information

List everyone that lives in your home.


 

PETS - Please complete as requested.

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 *


DOES YOUR FAMILY RECEIVE ANY TYPE OF ASSISTANCE?

Please select all that apply *


Household Income*

These questions do not determine your ability to receive services. 

Please list every family member receiving income.

If no income please enter Your name in Name #1, select NONE in Income Source, select Weekly in Pay Period #1, and enter zero in Dollar Amount.


Acknowledgement and Signature


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.  I also designate the following person(s) as an authorized representative(s) of my household and certify that their information is correct to the best of my knowledge.  Authorized representative(s) is/are able to pick up product for client.


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.

All applicants MUST sign this form digitally.

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

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