Senior Food Box Client Application

If you are an elderly adult in need of food help, you can apply for a monthly Senior Food Box. Please take a moment to review the eligibility requirements for this program:

You must be 60 years of age
The food is shelf stable and there is some simple cooking involved, so you will need access to basic cooking facilities
You or an authorized representative should be able to pick up your food box from a pickup location

"*" indicates required fields

First Name*

Last Name*

Address*

Street Address City State ZIP Code

County*

Do you have transportation or someone who could pick up your food box?*

Home/Cell Phone #*

Date of Birth*

Contact Email

Monthly Income*

Sex*

Disabled*

Living Arrangements*

Veteran Status*

Marital Status*

Race*

Ethnicity*

Authorized Representative

I authorize the following individual(s) to pick up my food box on my behalf if I become ill or unable to pick up the food on my own.

First & Last Name #1

First & Last Name #2

Client's Signature*

Please enter your first and last name. Filling out these fields and submitting this form constitutes your digital signature to the above information.

First Last

Date*

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Phone

This field is for validation purposes and should be left unchanged.