Assessment for Feed The Need Program 
  Thank you for reaching out to C.A.N.S. 4 CUTS 501c3. We are dedicated to supporting individuals and families in need through food donations. To help us better understand your situation and assess how we can assist you, please complete the following questionnaire. All information provided will be kept confidential.  
Email *
Name *
Phone: *
Email *
Address (including  City , State, Zip Code) *
Number of Household Members: *
Required
Please describe your current food situation and any challenges you are facing:
Do you or anyone in your household have any dietary restrictions or special dietary needs? *
If Yes please Specify:
Required
What is you estimated yearly  income? *
Required
Are you currently employed ? *
Required
Other (Please Specify) *
Do you receive any government assistance (e.g. SNAP,WIC) ? *
Required
Are you receiving assistance from any other food programs or organizations ?  *
Required
If yes please specify: *
How soon do you require food assistance? *
Required
What is your nearest Grocery Store *
Required
**Food Donation Intake Form Disclaimer:**

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge and that I consent to C.A.N.S. 4 CUTS 501c3 using this information to assess my eligibility for food assistance. I also acknowledge that C.A.N.S. 4 CUTS is not held responsible for any foods provided directly from a grocery store or delivery entities. *
Required
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