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

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* 6. Birth Date

Date

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* 7. Address

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* 8. Ethnicity (Check One)

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* 9. Race (Check all that apply)

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

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* 11. How many family members currently live in your home?

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* 12. What is your total annual income?

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* 13. Do you need assistance with:

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* 14. Are you already enrolled in:

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

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

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* 17. Does client live alone?

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

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

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