Groceries on the Geaux - Home Delivery Program Acadiana

On behalf of Second Harvest Food Bank, thank you for taking the time to complete this survey. This survey is to determine eligibility in the grocery home delivery program, Groceries on the Geaux. Please note, there are geographical and other limitations.

Survey information is shared with Second Harvest and a third party organization to determine program approval.

If you wish to be considered for this program, please answer the following questions.

Question Title

* 1. Please enter your contact information below.

Name

Address

Address 2

City/Town

ZIP/Postal Code

Phone Number

Question Title

* 2. What is your date of birth?

Date of birth

Date

Question Title

* 3. How many people live in your household?

1 - 4

5 - 8

Question Title

* 4. Do you have reliable transportation?

Yes

Question Title

* 5. Do you receive SNAP (also known as Food Stamps)?

Yes

Question Title

* 6. Do you or anyone in your home have the ability to prepare a meal?

Yes

Question Title

* 7. Please select how true the following statement was for your household over the past 12 months.
"We have worried our food would run out before we got more money."

Often true

Sometimes true

Never true

Question Title

* 8. Please select how true the following statement was for your household over the past 12 months.
"The food we bought just didn't last, and we did not have money for more."

Often true

Sometimes true

Never true

Groceries on the Geaux - Home Delivery Program Acadiana

Question Title

* 1. Please enter your contact information below.

Question Title

* 2. What is your date of birth?

Question Title

* 3. How many people live in your household?

Question Title

* 4. Do you have reliable transportation?

Question Title

* 5. Do you receive SNAP (also known as Food Stamps)?

Question Title

* 6. Do you or anyone in your home have the ability to prepare a meal?

Question Title

* 7. Please select how true the following statement was for your household over the past 12 months."We have worried our food would run out before we got more money."

Question Title

* 8. Please select how true the following statement was for your household over the past 12 months."The food we bought just didn't last, and we did not have money for more."

* 7. Please select how true the following statement was for your household over the past 12 months.
"We have worried our food would run out before we got more money."

* 8. Please select how true the following statement was for your household over the past 12 months.
"The food we bought just didn't last, and we did not have money for more."