Food Pantry Intake Form | Fresh Start Worship Center

Hello!

Thank you for visiting! We are here to provide food assistance to individuals and families in our community. To help us serve you better and understand your needs, we ask that you please complete this confidential intake form. The information you provide will help us maintain accurate records and connect you with other helpful resources if needed.

* All fields on the form must be completed in order to receive assistance. Completion of this form does not guarantee assistance. However, once this form has been reviewed someone from our staff will contact you within 2-3 business days of submission. If you have any questions, please call 614.973.9844. Thank you!

Date (Required)

Last Name (Required)

First Name (Required)

Your Phone Number (Required)

Address (Required)

E-mail Address

Number of People in Your Household (Required)

Household Information

How many individuals are ages 18 and over in your household? (Required)

How many children are under 18 in your household? (Required)

Do you receive any assistance? (Required)

SNAP

WIC

TANF

SSI

None of The Above

Food Allergies or Restrictions? (Required)

Do you or anyone in your household need any of the following items?

Diapers

Formula

Female/Male Hygiene

Laundry Detergent

Hats/Gloves/Coat

Signature (Required)

I certify that the information provided in this form is accurate and complete to the best of my knowledge. By signing, I acknowledge that I understand and agree to the terms of the intake process.

Client ID#:

FOR OFFICE USE ONLY

Staff /Volunteer Name

Solve 2 + 3 = ?

Fresh Start Worship Center

4905 Ridge Street
Columbus, OH 43207

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