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CLIENT INFORMATION FORM
REMINDER: THIS FORM ONLY NEEDS TO BE FILLED OUT ONCE. If you are looking for our delivery request form that can be found here - bit.ly/JustFoodDeliveryRequest

Once this form is completed you are eligible to shop at Just Food. Proof of residency, additional household members, and income are not required at this time.

Complete information (including date of birth) is required to add household members.
Last Name / Apellido *
First Name / Nombre *
Middle Initial / Inicial del medio
Date of Birth / Fecha de nacimiento *
Sex *
Address / Dirección *
City / Ciudad *
State / Estado *
Zip Code / Código Postal *
Email
Phone Number / Número de teléfono
Are you interested in Just Food Cooking Classes? / ¿Está interesado en clases de cocina de Just Food?
Clear selection
How did you hear about Just Food? / ¿Cómo supo de Just Food?
Race/Ethnicity (Raza/etnia)
Select all that apply / Selecciones todas las que apliquen
Preferred Language / Idioma que prefiere
Monthly Income / Ingresos mensuales
per month (before withholdings/deductions) / por mes (antes de quitar taxes y deducciones)
Main Income Source / Fuente principal de ingresos *
Required
Does your household currently receive food stamps (SNAP)? / ¿Está su hogar al momento recibiendo estampillas de comida (SNAP)?
Clear selection
If not, would you be interested in help filling out an application? / Si no está recibiendo estampillas ¿estaría interesado en llenar una aplicación?
Clear selection
Is your household currently on WIC Program? / ¿Está su hogar al momento en el programa WIC?
Clear selection
Is your household currently receiving TANF? / ¿Está su hogar al momento recibiendo TANF?
Clear selection
What is your employment situation? / ¿Cuál es su situación laboral? *
Required
Health/Dietary Restrictions (Restricciones de salud o dietarias)
Do you have health insurance? / ¿Tiene seguro médico?
Clear selection
Do you have a primary care provider? / ¿Tiene un proveedor de cuidado médico?
Clear selection
Transportation / Transporte
Select your primary method / Seleccione su método principal
Clear selection
Do you have additional household members? / ¿Tienen más miembros en su hogar? *
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