Food Intake Form

Name*

Phone*

Email

Date of Birth*

Gender*

Male
Female

Address*

Ethnicity*

Hispanic or Latino
Not Hispanic or Latino

Race (check all that apply)*

White
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
Black or African American

How many people are in your household?*

Please list the names, birthdates, genders, ethnicity, and race of ALL the people living in your household

Please don't include yourself

1

Date of birth

Gender

Ethnicity/ Race

2

Date of birth

Gender

Ethnicity/ Race

3

Date of birth

Gender

Ethnicity/ Race

4

Date of birth

Gender

Ethnicity/ Race

What is your household's total monthly income?*

Include income from all members of the household and all types of income: wages, social security, disability, etc.).

Within the past 12 months have you worried that your food would run out before you got money to buy more?*

Yes
No

Within the past 12 months did the food that you bought just not last and you didn't have money to get more?*

Yes
No

Have you ever applied for CalFresh/SNAP (Food Stamps) benefits?*

Yes
No

If you have ever applied for food stamps, are you currently receiving benefits?

Yes
No

Are you a military veteran or active military?*

Yes
No

Do you currently have health coverage?*

Yes, for myself
Yes, for the whole family
Yes, only the kids
No

Type

Private Insurance
Medicare/Medicaid
Veteran's Benefits
Indian Health Service
Disability

Do you or anyone in your household receive food assistance from any of these programs?

CSFP (Commodity Supplemental Food Program/Senior Food box)
Other Food Pantries
Soup Kitchen
School Breakfast/Lunch
Summer Meal Program
WIC (Women's, Infant's & Children's Program)

Check all that apply

Consent*

I agree to the privacy policy and self-certification.

I understand that I am self-certifying my income eligibility for this program. I understand that my basic, identifying, and non-confidential service transactions/information will be shared in an electronic shared case database administrated by the Food Bank of Northern Nevada called “Oasis Insight” and may be shared with California Health and Human Service Agencies who provide our food.

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