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COVID19

Coronavirus Information

VCAAA FOOD RESOURCES FORM

Homelessness and Housing | Unemployment | General/Food Resources | Resources to Print

We encourage people to see if family, friends, or neighbors can help with getting food and groceries at this time. If you are still in need of food assistance, please complete and submit the information below:

Name *

First

Last

Street address

City

Phone number

Date of birth (mm/dd/yyyy)

Primary language

Race

Ethnicity

Low income

Yes
No

Do you live alone?

Yes
No

Do you currently receive home delivered or congregate meals?

Yes
No
Unsure

Number of older adults and people with disabilities in your home

Are you unable to leave home (due to VC mandate and/or because of physical limitations)?

Yes
No

Are you able to order food online?

Yes
No

How many days worth of food do you currently have?

Where or how do you normally get your food?

Do you currently get food from food pantries or Food Share?

Yes
No

Name

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