Backpack Program Emergency Food Survey

Question Title

* 1. How is your family holding up at this time?

Very good

Good

Fair

Bad

Very Bad

Comment

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* 2. Does your family have any health related food needs?

Yes

No

Question Title

* 3. If you answered Yes to the last question, what specifically are those special food needs? Please select all that apply.

Diabetic

Gluten Free

Peanut or Nut Allergy

Dairy Free

Other (please specify)

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* 4. Please go to Hudson Backpack's website for a list of community services and resources available in our area: Hudson Backpack Program