Eligibility:*I am a new client   It has been 28 days since I requested food from Life Station   
Pick up or delivery? If delivery, why do you need delivery?*
First Name, Middle Initial, Last Name*
Street Address*
Address Line 2 (Apt, Lot, etc)
City*
County*
Zip Code*
Apartment Complex Name*
Phone Number*
Phone Type*
Can we text you?*
Birthdate*
Email Address*
Marital Status*
Gender*
Household with a Veteran*
Total number of people in your household (including you)*
Total 0-5 years old*
Total 6-12 years old*
Total 13-17 years old*
Total 18-59 years old*
Total 60+ years old*
First and last name of additional person 1
Relation to you
Their birthdate
First and last name of additional person 2
Relation to you
Their birthdate
First and last name of additional person 3
Relation to you
Their birthdate
First and last name of additional person 4
Relation to you
Their birthdate
First and last name of additional person 5
Relation to you
Their birthdate
First name, last name, relation to you and birthdate of any other persons in your household not yet listed*
Are you a Christian*
Do you have a home church?*
Name of church
Attendance Frequency
Do you need a new church home?*Yes   No   Prefer not to say   
Would you like a FREE Bible study that comes in the mail?*Yes   No   
Do you want encouraging phone calls/texts?*Yes   No   
Would you like FREE RightNow Media (Christian streaming service)?*Yes   No   
I understand that I have to be home to sign a form for every delivery and no one can sign for me.*I understand   I do not understand   
I understand that I must sign a form stating my household income is under 200% of federal poverty level for my household size. (We do not require proof.)*I understand   I do not understand   
Please enter your name to state that all info is correct to the best of your knowledge.*
If you are an Authorized Representative for this client and have asked them ALL questions on this form, please put your name here.
Please enter your organization/relationship, phone and email.