Healthy Essentials Form | Giving to the Nations Racine

Household Information

How many people live in your house in the following age/gender groups and indicate how many are male or female

Females Under 5 Years

Males Under 5 Years

Females 5-9 Years

Males 5-9 Years

Females 10-14 Years

Males 10-14 Years

Females 10-14 Years

Males 10-14 Years

Females 15-17 Years

Males 15-17 Years

Females 18-24 Years

Males 18-24 Years

Females 25-34 Years

Males 25-34 Years

Females 35-44 Years

Males 35-44 Years

Females 45-54 Years

Males 45-54 Years

Females 55-64 Years

Males 55-64 Years

Females 64-85 Years

Males 64-85 Years

Females 85 and over

Males 85 and over

PETS - Please enter a number for each.

Dogs

Cats

Other Pets

Acknowledgement and Signature

Was there an emergency situation which caused you to contact us?

Yes

Briefly explain your current situation:

What need(s) do you or your family have right now? Please state the need(s) and be specific:

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 until re-certification is necessary.

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.

Name of Authorized Representative(s)

Authorized Rep 1

Authorized Rep 2

Authorized Representative(s) Address/Phone

Authorized Rep 1

Authorized Rep 2

All applicants MUST sign this form digitally.

Client Signature

Date

NOTE: These questions do not determine your ability to receive services. This information is collected for tracking the need for future services and for obtaining additional funding to support our programs.

(office use only)

Pick up Person: _______________________________________________________ Pick up Date: __________________

Healthy Essentials Pantry

Giving to the Nations - Client Intake Form

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

CLIENT DOCUMENTATION

CLIENT INFORMATION

Household Information

MILITARY STATUS

PLEASE SELECT YOUR RACIAL CATEGORY

PLEASE SELECT YOUR ETHNIC CATEGORY

DOES YOUR FAMILY RECIEVE ANY TYPE OF ASSISTANCE?

Household Income*

Acknowledgement and Signature

CLIENT ACKNOWLEDGEMENT

All applicants MUST sign this form digitally.

Contact

Quick Links

Stay in Touch

Feel free to join our mailing list and we will keep you updated about events, giveaways and service opportunities as well as any news about us and the state of Hygiene Poverty

Healthy Essentials Pantry

Giving to the Nations - Client Intake Form

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

CLIENT DOCUMENTATION

CLIENT INFORMATION

Household Information

MILITARY STATUS

PLEASE SELECT YOUR RACIAL CATEGORY

PLEASE SELECT YOUR ETHNIC CATEGORY

DOES YOUR FAMILY RECIEVE ANY TYPE OF ASSISTANCE?

Household Income*

Acknowledgement and Signature

CLIENT ACKNOWLEDGEMENT

All applicants MUST sign this form digitally.

Contact

Quick Links

<img class="size-medium wp-image-2264 alignleft" src="https://mlmnfgfhcrnj.i.optimole.com/makhdcU-bRmb7ePD/w:300/h:160/q:auto/http://givingtothenations.org/wp-content/uploads/2020/12/photo-1584724109209-b7d1f0368715.jpeg" alt="" width="300" height="160" />

Stay in Touch

Feel free to join our mailing list and we will keep you updated about events, giveaways and service opportunities as well as any news about us and the state of Hygiene Poverty