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Intake Application

Please answer all questions carefully so we may better serve you and your family. Your information is confidential and will not be shared with any outside agency or entity. 


What is your household size?
How many of those are children?
Which of the following best describes you?
Asian
Black or African American
Caucasian/White
Hispanic or Latino
Middle Eastern
Biracial or Multiracial
Prefer not to say
Do you or your family members have any allergies or food restrictions? (Select all that apply)
What is your total household income (pre-tax)?
$0
$1 to $9,999
$10,000 to $24,999
$25,000 to $49,999
$50,000 to $74,999
$75,000+
Does your family receive any type of assistance?
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