Application

Please complete an Inforamtion Page. Te information you provide will be kept confidential.

Print applicsation and bring with you when you shop for the first time.

* When you attend a class you recieve a weeks woth of groceries.*

Please submit information completly below.

Name of head of household__________________________________________________________________________________________________________________________________

Address ______________________________________________________________________________________________________________________________________________

Phone Number ________________________________________ Email ____________________________________________________________________________________________

Income source (employment/SSI/SSD/Welfare/Other)

Amount of monthly income $_________________________________

Foodstamps $_______________________________ Medicare/Medicaid ____ Houseing ______ Other _____________

Members in your Household

Name Birthday Age Gender Relationship

______________________________________________________________________________________________________________________________________________

Are you interested in classes in: Buedgeting Healthy Cooking Health Improvemenet Parenting Other ______________________________________________________________________________________________________________________________________________

Office Note:

approvede by:_____________ date_____________ verified by _______________ date4__________ USDA Crt.________ date _______________