Visitor sign-up — Village Hills Fellowship

Basic information

For fields that do not apply, enter None. * Required

First name *

Last name *

Visit date *

Contact & address

No fixed address *

YesNo

Street address *

City *

State *

ZIP code *

County *

Email address *

Phone number *

Preferred communication *

May we contact you about pantry services? *

YesNo

Would you like information about other resources? *

YesNo

No ID is required.

Household

Other household members who will benefit today (not including yourself) *

People outside your household picking up food for you *

Does anyone in your household receive SNAP or food stamps? *

Household income

Choose one time period and enter your household income amount. Enter 0 if none.

Income time period *

Household income ($) *

Is your household in crisis? *

YesNo

More about your household

Age *

Gender identity *

Race / ethnicity (select all that apply) *WhiteHispanic, Latino, or SpanishBlack or African AmericanAsianAmerican Indian or Alaska NativeMiddle Eastern or North AfricanNative Hawaiian or Other Pacific IslanderSome other race or ethnicityDon't know / Prefer not to answer

U.S. military veterans in your household (including yourself) *

Preferred language(s) *

Do you need translation services? *

YesNo

Did anyone work full-time for pay in the last month? *

Does anyone have a disability preventing work for the next six months? *

What's your living situation today? *

Has anyone served on active duty in the U.S. Armed Forces? *

Food & assistance

In the past 30 days, we worried our food would run out before we got money to buy more. *

In the past 30 days, the food we bought didn't last and we didn't have money to get more. *

Additional notes *

Welcome — let's get you signed up.

Basic information

Contact & address

Household

Household income

More about your household

Food & assistance