Food Assistance Program Assessment Form
Personal Information
Full Name
Date of Birth
Phone Number
Email Address
Home Address
City
ZIP/Postal Code
Household Information
Household Size
Number of Children
Number of Adults
Number of Seniors (65+)
Income & Employment
Employment Status
Employed
Unemployed
Student
Retired
Other
Monthly Household Income
Food Needs
Have you received food assistance before?
Yes
No
Dietary Restrictions / Allergies
Comments or Specific Food Needs
Other Programs
Are you currently enrolled in other assistance programs?
SNAP
WIC
SSI
Medicaid
None
Other
If yes, please specify
Additional Information
Additional Comments