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INDIVIDUAL AND FAMILY ASSISTANCE
Please fill out the following form so we can best serve you and your family.
Name
*
Email
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Address
Address Line 1
Address Line 2
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Which county do you live in?
Medina
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Do you need food delivered?
Yes
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Number of People In Household
*
1-4 people
1-10 people
10+ people
Are you
Employed
Unemployed
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SNAP Recipient
Please tell us about family members
*
Seniors in the home
Infants/Toddlers in the home
K-12 students in the home
Pets (Dogs/Cats/Hamsters)
Food Allergies?
Nuts (Peanuts, Coconut)
Shellfish
Gluten Sensitivity
Best Time To Contact?
*
Before 8 AM
Work Hours (8 AM - 5 PM)
Evenings (After 6 PM)
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