Hand Up Pantry Food Assistance Interest Form

Name*

First NameLast Name

Date of Birth*

Date

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Including yourself, how many people are in your household?*

What is the primary source(s) of income for your household?*

What is your gross annual household income?*

Total yearly income before taxes

Are you currently receiving CalFresh benefits (EBT, Food Stamps)?*

YesNo, but I'd like help applyingNo, and I'm not interested

Are you currently working with a program or staff member at Jewish Family Service? (other than food assistance)*

YesNo

Do you, or anyone in your household, identify as Jewish?*

YesNo

Do you have any conditions that require you to eat a medically supportive diet?*

YesNo

The Hand Up Food Pantry has a very limited availability for individuals not actively enrolled with JFS Case Management Programs. If we are unable to enroll you in the Hand Up Food Pantry, would you like to receive information about other available food resources?*

Yes, send me information about other food resources across the county.Yes, send me information on online ordering for curbside pickup at JFS.No, I do not want information on other available food resources.

Hand Up Food Assistance Interest Form