Food Hamper Delivery Application

Name*

First Last

Primary Phone*

Secondary Phone

Address*

Street Address Address Line 2 City Province Postal Code

Email

Birthday*

Other Individuals in Household (name, age, relationship to you)*

NA if not applicable

Pets (List types of pet and name)

NA if not applicable

Sources of Income*

Disability
Social Assistance

Mobility Requirments:*

Wheelchair
Walker
Cane
Crutches
Oxygen
Other
Not Applicable

List all the agencies you receive help or support from:*

NA if not applicable

If referred, Referrer's name

First Last

If referred, Referrer's phone number

What current situation is preventing you from being able to pick up your own food bank hamper?*

Do you expect this situation to change in the next 6 months?*

Yes
No

Do you or anyone in you household currently own a licensed vehicle?*

No
Yes
If yes, please explain below.

Is there anyone in your household or community that could pick up your food bank hampers on your behalf?*

No
Yes
If yes, please explain below.

I acknowledge that in order to receive this service:*

I must be home on Thursdays between 10am and 2pm for delivery
I must have a working phone and be able to be contacted by call or text
If my hamper is undeliverable 3 times in a calendar year I forfeit the utilization of this service
I will update my address and phone number if it changes from the time of my first application
My eligibility will be reviewed every 6 months

Please include detailed home delivery instructions. (ie. Buzz Code, Go Through Carport, Call ahead and I'll meet you downstairs)*

Personal Information Release*

I, (applicant print name below) approve the release of my personal information as shown above with the understanding that this information is required to participate in the Hands in Service program or receive Hands in Service assistance and will only be provided to Hands in Service staff, volunteers or relevant health care providers as part of the Hands in Service program to ensure appropriate service delivery.

First Last

Applicant Signature

Please type your first & last name with today's date as an electronic signature.

Food Hamper Delivery Form