Home Delivery Pilot Project

Pre-Registration for Home Delivery

Thank you for your interest in applying for home delivery of emergency food boxes. El Pasoans Fighting Hunger is conducting pre-registration for home delivery of food for people and families who need additional support during this time. We are testing a pilot program for those who are quarantined due to diagnosis or pending diagnosis of covid-19. Home deliveries will be for the entire household. If you would like to find out if you are qualified, please complete this survey and a staff member will contact you soon.

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* 1. Please enter date form is filled out.

Date

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* 2. Last Name

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* 3. Middle Initial

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* 4. First Name

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* 5. Gender

Male

Female

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* 6. Birth Date

Date

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* 7. Address

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 8. Ethnicity (Check One)

Hispanic or Latino

Not Hispanic or Latino

Ethnicity Not Reported

Other (please specify)

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* 9. Race (Check all that apply)

White -- Non Hispanic

White -- Hispanic

American Indian/Alaska Native

Asian

Black or African American

Native Hawaiian or Pacific Islander

Persons Reporting Some Other Race

Race Not Reported

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* 10. Disability

Yes

Prefer not to answer

N/A

Don't Know

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* 11. Client living in poverty (low income)?

Yes

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* 12. Including yourself, How many family members currently live in your home?

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* 13. If applicable, What is the name, D.O.B and relationship of all household members?

Household member 1, D.O.B, relationship

Household member 2, D.O.B, relationship

Household member 3, D.O.B, relationship

Household member 4, D.O.B, relationship

Household member 5, D.O.B, relationship

Other Household members, D.O.B, relationship

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* 14. What is your total monthly income?

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* 15. What is your Primary Income Type

Employment

Social Security

Unemployment

Retirement/ Pension

Disability Assistance

No Income

Other (please specify)

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* 16. Are you already enrolled in:

SNAP

CHIP

Medicaid

Disability

Other (please specify)

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* 17. Do you need assistance with:

SNAP

CHIP

Medicaid

Disability

County Meal Program

Other (please specify)

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* 18. Are you or a member of your family quarantined due to a diagnosis or pending diagnosis of COVID-19?

Yes

Other (please specify)

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* 19. How long do you estimate you will need home delivery of emergency food boxes? (Only check one)

2 weeks

2 months

3 months

6 months

Indefinitely

Why? (please specify)

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* 20. Does client live alone?

Yes

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* 21. Do you have friends or family members who can bring you food?

Yes

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* 22. Can you afford to pay for a service to bring you food?

Yes

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* 23. Are you a Veteran in the armed forces of the United States?

Yes