TEST Page

Name*

First Last

Are you 60 or older?*

Yes
No

Address*

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

Phone*

Is this a cell phone or a landline?*

Cell Phone
Landline

Can this number receive text messages?*

Yes
No

Email

Would you like to add your email address to the voucher mailing list, in order to stay up to date on any changes with the program?

Yes
No

Date of Birth*

Food Bank ID

if applicable - found on your food bank photo ID card which you can get at the foodbank

Race

Monthly Income for all household members?*

Number of Persons in Your Home**

Are there Persons in your home who are:

Elderly (60 and over)
Children under 10

How did you hear about St. John's UMC?

Preferred Language

English
Spanish
Other

Questions/Concerns

NOTICE*

I agree to the privacy policy, listed below.

St. John's participates in a client tracking program and will share client information with other agencies in our tracking system to avoid duplication of services. I hereby give SPFB permission to communicate with the central tracking agency and any other agency, church, or individual as necessary, to complete or verify my request for assistance. I understand that this information will be used only for the above-stated purpose and that this information will be confidential. Furthermore, I attest the information I have provided is accurate and correct to the best of my knowledge.

Digital Signature - Please Type Your Full Name*

Date*