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Almanor Basin Food Pantry Intake Form

Welcome to the Almanor Basin Food Pantry. To better help you and your family, we ask that you take a few minutes to complete this short form. We ask these questions as a way to get to know you and to understand how we can better meet the needs of our community. If you have any questions or concerns, please do not hesitate to ask any food pantry staff member or volunteer. Thank you and have a great day!

TEFAP-Only recipients are only required to complete the items. Almanor Basin Food Pantry is an equal opportunity provider.

Name

Email

Gender

Gender
A
B
C
D

Phone

Active Duty/Military Veteran?

Active Duty/Military Veteran?
A
B

May we use this information to contact you with updates?

May we use this information to contact you with updates?

Date of Birth

Street Address

City

Zip Code

Ethnicity

Ethnicity
A
B

Race (mark all that apply)

Race (mark all that apply)

Please list the names, birthdates, genders, ethnicity and race of all other people in your household:

What is your household's total monthly income? (Include income from ALL members of the household and ALL types of income: wages, Social Security, Disability, etc.): $ per month.

My income is at or below the income listed for the number of people in my household?

My income is at or below the income listed for the number of people in my household?
A
B

I am eligible to receive food from TEFAP because my household participates in SNAP, WIC, Free and Reduced Lunch Program (school meals), TANF, or SSI?

I am eligible to receive food from TEFAP because my household participates in SNAP, WIC, Free and Reduced Lunch Program (school meals), TANF, or SSI?
A
B

Within the past 12 months have you worried that your food would run out before you got money to buy more?

Within the past 12 months have you worried that your food would run out before you got money to buy more?
A
B

Within the past 12 months did the food that you bought just not last and you didn't have money to get more?

Within the past 12 months did the food that you bought just not last and you didn't have money to get more?
A
B

Within the past 12 months, have you or anyone in the household applied for SNAP (Food Stamps) benefits?

Within the past 12 months, have you or anyone in the household applied for SNAP (Food Stamps) benefits?
A
B
C

Are you aware of the Food Bank of Northern Nevada helping with SNAP applications?

Are you aware of the Food Bank of Northern Nevada helping with SNAP applications?
A
B

Does anyone in the household currently have health coverage?

Does anyone in the household currently have health coverage?
A
B

What type of Health coverage do the Household members have? (Check all that apply)

What type of Health coverage do the Household members have? (Check all that apply)
A
B
C
D
E
F
G
H
I
J

What are your household's favorite kinds of foods?

What do you feel causes the need for food assistance? (Check all that apply)

What do you feel causes the need for food assistance? (Check all that apply)

Do you or anyone in your household receive food from any of these programs? (Check all that apply)

Do you or anyone in your household receive food from any of these programs? (Check all that apply)

I understand that my basic, identifying and non-confidential service transactions/information will be shared in an electronic shared case database administered by the Food Bank of Northern Nevada called Oasis Insights.

I understand that my basic, identifying and non-confidential service transactions/information will be shared in an electronic shared case database administered by the Food Bank of Northern Nevada called Oasis Insights.

Signature

Signature

Date