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Alameda County Emergency Food Distribution First-Time Customer Sign-In Survey [Template]
[Name of Contractor/Subcontractors]

Please complete only one survey per household one time. Do not complete survey if you have already done it before.
Email address *
Name
(We will not share your name in connection with your survey responses. All survey responses will be combined and reported anonymously.)
Zip code *
Provide the zip code where you live.
Phone number *
(We will not share your phone # with your survey responses. This is only used to help you sign-in faster next time and for staff to contact you.)
Email address
(We will not share your email address in connection with your survey responses. This is only used to let you know about food and food assistance resources in your area.)
I am interested in receiving: *
Total number of people in my household, including myself: *
Ages of all household members: In each row, select the number of people in each age group in your household. *
0
1
2
3
4+
Ages 0-17
Ages 18-26
Ages 27-59
Ages 60+
Race/ethnicity of all household members: In each row, select the number of people in each group in your household. *
0
1
2
3
4
5+
African-American/Black
Asian/Pacific Islander
Latina/Latino
Native American/American Indian
Mixed Race
White/Caucasian
Other: __________________________________
Decline to state
One or more people in my household (check all that apply):
One or more people in my household is experiencing (check all that apply):
One or more people in my household receives one or more of the following public benefits (check all that apply): *
Required
Type any questions or comments for us here.
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