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Crosstown Community Driven Initiative Applicant Waiting List

Driving Community Forward Applicant Waiting List

This form is to request placement on the waitlist for delivery sponsored by Community Partnerships. This program provides  of groceries, prescriptions, and basic essentials to qualifying residents within the Medina service area.

Eligibility is based on factors such as age, income, household size, and participation in other assistance programs. Completion of this form does not guarantee service but ensures your request will be reviewed. If your initial request is approved for consideration you will be contacted to provide additional verification regarding your situation. Priority consideration is based on need and availability. 

Please complete all sections accurately. Incomplete applications WILL BE DISCARDED.  

Your Information
State

Your Situation

On a scale of 1-10, how would you rank your Ability To Independently Access Everyday Essentials Like Groceries And Medication?

On a scale of 1-10, how would you rank your Ability To Independently Access Everyday Essentials Like Groceries And Medication?

Please List All Major Obstacles You Feel Prevent You From Accessing Everyday Essentials Like Groceries And Medication?

Number Of People In Household

Do You Have A Personal Care Attendant (Service or Family Member? Who?

Do You Receives Public Assistance? What Type

Referred By?

Notes / Special Requests

Disclaimer

By submitting this form, you consent to the collection and review of your personal information for the purpose of evaluating eligibility for participation in the program. All information provided will be stored securely and used solely for internal program administration and communication.

Crosstown Runzzz, its affiliates, and authorized agents will not disclose your personal data to any third party without your explicit written consent, except as required by law. This form is not a contract and does not guarantee services. Services are contingent upon funding, capacity, and eligibility verification.

By clicking the yes button below, you're agreeing to the disclaimer and that all of the information you've provided above is accurate and up to date to the best of your knowledge.
Disclaimer