The Love Food Network Mobile Food Pantry request form

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Welcome to UNI Cares Mobile Food Bank Assistance!

Please fill out this form to help us understand your needs and deliver the right support directly to you. Your information will remain confidential and be used only to improve our services.

Personal Information

* Full Name (first name and last name)

0/50

* Contact phone number (702-123-4567)

0/50

* Contact email address (jack702@yahoo.com)

0/50

* Physical Address (1234 Main Street, Las Vegas, NV 89120)

0/250

Household Information

* Number of Adults (18+)

0/50

* Number of Children (under 18)?

0/50

* Are any household members elderly or disabled?

Yes

* Veteran Status

Yes

* Type of Insurance?

None

Private

Medicare

Medicaid

Other

* Employment Status?

Employed

Unemployed

Retired

Other

* Income Level?

$0 - $10,000

$10,000 - $20,000

$20,000 - $30,000

$30,000 - $40,000

$40,000 - $50,000

$50,000 - $60,000

* Ethnicity/Race

Asian

American Native/Alaska Native

Black/African American

Caucasian/White

Hispanic/Latino

Native Hawaiian/Other Pacific Islander

Other

* Primary Language Spoken (English, Spanish, Chinese etc.)?

0/50

* Disability Status?

Yes, I am disabled

No, I am not disabled

* Internet Access at Home?

Yes

* Reliable Transportation?

Yes

Food Assistance Needs

* Preferred Delivery Day(s)

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

* Dietary Restrictions?

0/250

* Food Preferences?

Dairy (Milk, Cheese etc)

Meat

Fresh Produce and Fruit

Dry Pantry Items (cookies, crackers, cereal etc)

Interest in Additional Services

* Please indicate if you are interested in receiving information about the following services.

Employment Assistance

Health and Welfare Programs

Financial Counseling

Childcare Services

Senior Care Services

Educational Programs

Legal Aid Services

Housing Assistance

Harm Reduction Services

Consent and Privacy

* Consent to Contact and Deliver

I consent to be contacted by UNI Cares via phone or email regarding my application and related services.

* Data Privacy Agreement

I agree that my information can be used for reporting purposes and to receive additional assistance as requested. I understand that my data will be kept confidential and secure.

Thank You for Submitting Your Application!

Your form has been received, and we will be in touch soon to coordinate your food delivery. If you need immediate assistance, please contact us at 702-609-6980. We’re here to help!

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UNI Cares Project | 2375 E Tropicana Ave Suite 8 PMB 153 | Las Vegas, NV 89119 US

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