Florence Food Share

Florence Food Share Intake Form For Emergency Food Assistance PLEASE PRINT CLEARLY

Name ______Transient / Traveler LAST FIRST MI Homeless

Address Tent/Outdoor camping Verified: Street Address ______Live in RV / Camper (street address only, no Post Office boxes or Private Mail Service boxes) Yes ___ Cell ___ Msg No City ______State _____Zip ______Phone (____)______Home ___ Work Enter the number of people living in your household (those who share your food); include yourself: No. of adults: ______(18 & over) No. of children ______(17 & under)

Household Size Gross Monthly Income Household Size Gross Monthly Income 2014 1 ……………………..……. $ 1,799 6 …………..………………. $ 4,929 ELIGIBILITY 2 …………………..………. $ 2,425 7 …………..………………. $ 5,555 GUIDELINES 3 …………………..………. $ 3,051 8 …………..………………. $ 6,181 4 …………………..………. $ 3,677 9 …………..………………. $ 6,807 5 …………………..………. $ 4,303 10 …………..………………. $ 7,433

By signing below, I declare that my household income is at or below the eligible income guidelines shown above, OR that I am currently participating in the SNAP (Food Stamp) Program, TANF (Temporary Assistance for Needy Families), SSI (Supplemental Security Program), LIHEAP (Low Income Home Energy Assistance Program), or State General Assistance. I also affirm that my address and the number of people in my household are true and accurate, and that I will not sell, barter, or trade the food received.

SIGNATURE______DATE______

The following information is optional and will not affect your ability to receive a food box. It is requested in order to provide you better service, and for reporting purposes. List all household members who live and eat with you. Include gender, ages, ethnicity and race, using the following letter codes for racial categories.

Race Code Diet Needs D = Diabetic GF = Gluten Free W = White / Caucasian AI = American Indian / Alaska Native V = Vegan / Vegatarian HP = High Protein B = Black / African NH = Native Hawaiian / Pacific Islander LI = Lactose Intolerant NS = Nutritional Supplements A = Asian M = Multiracial (more than one race) LS = Low Sodium U = Unknown or decline to answer

Hispanic or Diet Age Gender Race Names (first & last) Latino? needs 1. (Self) M F Yes No 2. M F Yes No 3. M F Yes No 4. M F Yes No 5. M F Yes No 6. M F Yes No 7. M F Yes No 8. M F Yes No 9. M F Yes No 10. M F Yes No

Revised 7/29/14 COMPLETE BOTH SIDES Page 1 of 2 PERMISSION FOR OTHERS TO PICK UP FOOD BOX

Any adult in your household may shop. You may have others, who are not part of your household, come to Food Share to shop for you. Individuals must be 18 or older.

I authorize the following individuals, not in my household, to shop for me. I understand that Food Share is not responsible for the food choices these individuals would make. [Please print first & last names]

1. ______

2. ______

3. ______

SHOPPING PANTRY GUIDELINES

 Households will receive a three to five day supply of food, depending on how much food we have on hand during the day you are shopping.

 One adult per household will be allowed in the food area to shop. Caregivers may assist their clients.

 Children are not allowed in the food shopping area of the pantry. Children that can sit quietly on their own are allowed to wait in the lobby area of the pantry while their caregiver shops. Infants must be attended by their caregiver at all times. A Food Share Volunteer will shop for the client that has infants, and small children who require supervision, while that client waits in the lobby with those children.

 Clients will shop with the assistance of a volunteer.

 Clients may select the number of items (per household size) posted on the front of each shelf.

 Clients may refuse to take food items, but may not take more of another item to make up the difference.

 Please be aware of other shoppers in line behind you. While you are welcome to look at the various choices, please know that we need to keep the line moving at a reasonable pace in order to accommodate all clients each day.

 Volunteers will select the food from the refrigerators and freezers for the clients.

 Florence Food Share reserves the right to withhold service if safety or bad behavior becomes an issue.

Revised 7/29/14 COMPLETE BOTH SIDES Page 2 of 2