EmailMe Form - FOOD BANK BENEFITS APPLICATION

Name *

First Last

Date of Birth *

MM / DD / YYYY

Phone *

### - ### - ####

Email

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Residence

RENT

OWN

CAMPING

OTHER

Specifically for those who live in Sedona, Village of Oak Creek, Cornville, or Page Springs.

Verifiable proof of residency required from Sedona, Village of Oak Creek, Cornville, or Page Springs, such as but not limited to the following:

-Driver’s license
-Arizona ID
-Utility bill
-A child’s report card from local school
-Rental agreement or receipt of payment
-Correspondence, ie: phone bill, insurance (car or health) bill
-Camping receipt
-P.O. Box

All persons in the household must show proof of residency.

*Without proof of residency, only limited assistance will be available.

Upload your verification file

Household Size. List members in household if more than one. *

Name

First Last

Date of Birth

MM / DD / YYYY

Relationship

Name

First Last

Date of Birth

MM / DD / YYYY

Relationship

Name

First Last

Date of Birth

MM / DD / YYYY

Relationship

Name

First Last

Date of Birth

MM / DD / YYYY

Relationship

Name

First Last

Date of Birth

MM / DD / YYYY

Relationship

Check the sources of income - We may use this information to obtain grants for support.

Check if you have these monthly expenses

RENTAL

PUBLIC SERVICES

Is there more than you would like to tell us about your change in circumstances that brought you here?

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)

LIST ANY SPECIFIC TYPES OF FOOD YOU PREFER FOR CEREAL, PASTA, OR OTHER FOODS.

Signature *

Clear