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Application for Home-Bound Food Delivery Benefits
To qualify for home-bound food benefits, applicants must be home-bound due to age or health-related issues. Delivery of food is the second Monday of every month between 10am and 1pm.
Name
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First
Last
Phone
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Email
Address
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Street Address
Address Line 2
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State / Province / Region
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Country / Region
Household Size
1 Person
2 Person
QUESTIONAIRE
We want to be sure that food given to your family is food you want to eat. Our objective is to offer food that will be enjoyed and not wasted. Please put a check mark next to those foods your family would prefer.
FOOD ALLERGIES?
YES
NO
Food allergies, special medical conditions (such as diabetes), or food needs - if you prefer to say so.
FOOD TYPE PREFERENCE: (Check all that apply)
VEGAN
VEGETARIAN
GLUTEN-FREE
DIABETIC
PREFERRED FOODS: (Check all that apply)
HOT CEREAL
COLD CEREAL
TOMATO SOUP
CHICKEN NOODLE SOUP
CREAM SOUP
VEGETABLE SOUP
CLAM CHOWDER
BEEF SOUP
CANNED GREEN BEANS
CANNED PEAS
CANNED CORN
CANNED MIXED VEGETABLES
TOMATO SAUCE
SPAGHETTI SAUCE
CANNED TOMATOES
OTHER VEGETABLES
CANNED PEACHES
CANNED APRICOTS
CANNED PEARS
FRUIT COCKTAIL
CANNED PINEAPPLE
OTHER FRUIT
BLACK BEANS
KIDNEY BEANS
NAVY/WHITE BEANS
DRY PINTO BEANS
CANNED PINTO BEANS
GARBANZO BEANS
BLACK-EYED PEAS
REFRIED BEANS
BROWN RICE
WHITE RICE
RICE-A-RONI
SPAGHETTI
MAC & CHEESE
RAMEN
OTHER PASTA
CREAMY PEANUT BUTTER
CRUNCHY PEANUT BUTTER
JELLY
TUNA
CANNED CHICKEN
PORK & BEANS
FAT FREE MILK (if available)
1% MILK (if available)
2% MILK (if available)
WHOLE MILK (if available)
YOGURT (if available)
CHEESE (if available)
EGGS (if available)
BUTTER (if available)
JUICE (if available)
LUNCH MEAT (ANY)
TURKEY LUNCH MEAT (if available)
BEEF LUNCH MEAT (if available)
HAM LUNCH MEAT (if available)
BOLGNA LUNCH MEAT (if available)
WHITE BREAD
WHOLE WHEAT BREAD
MULTI-GRAIN BREAD
OTHER BAKED GOODS
ANY FRESH FRUITS OR VEGETABLES
BANANAS (if available)
APPLES (if available)
ORANGES (if available)
CARROTS (if available)
TOMATOES (if available)
ONIONS (if available)
LIST ANY SPECIFIC TYPES OF FOOD YOU PREFER FOR CEREAL, PASTA, FRUITS, VEGETABLES OR OTHER FOODS.
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