Giving to the NationsĀ  –Ā  devoted to advancing the lives of others

Giving to the NationsĀ  -Ā  devoted to advancing the lives of others

Giving to the Nations

Healthy Essentials Pantry

We’re here to help you and your family with items needed for your personal and home care.

Healthy Essentials Pantry Application Process

In order to help you, we need your help. Please complete theĀ  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

Client Intake Form

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

CLIENT DOCUMENTATION

Ā 

CLIENT INFORMATION

Ā 

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, baby or home cleaning products delivered free to you by DoorDash.


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 *


PLEASE SELECT ALL BOXES THAT APPLY TO ANY ASSISTANCE YOUR FAMILY IS RECEIVING and YOUR EMPLOYMENT STATUS*


TOTAL ANNUAL HOUSEHOLD INCOME*

This information does not determine your ability to receive services.


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.Ā  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.Ā  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.

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
Newsletter Form widget