Resident Service Intake
By completing the form below you are confirming that we may use your information to provide the requested services needed. You are confirming that all provided information is true to your knowledge. In order to receive services or food delivery, you must complete the form below.

* While all food remains FREE Deliveries include a $2.00 delivery fee per delivery. Would you like to continue delivery services or schedule to pick up from 2701 St.Clair Ave Cleveland Ohio 44114 ? *
How would you like to complete your payment? *
First and Last Name *
Phone Number *
Full Address *
Date of birth *
Last 4 Digits of your SSN *
Are you interested in a FREE phone service that provides 4Gs of internet data, Unlimited text, and 1000 talk minutes per month ? *
How much do you earn per week? *
Is anyone in the house disabled or dealing with a medical condition? *
Are there youth in the house age 0-18? *
Please list their names and birth month *
Do you or anyone in the household have dietary restrictions? *
If they answered yes to the above question, what are the restrictions?
How was your experience with our team and services? *
Were you able to utilize any of the items given to you? *
Did you feel safe? *
Are there emergency items that you need? *
If answered yes, explain. If answered no, type N/A *
How can we improve our services ? *
Which days are you available to receive a delivery ? *
If you’re located in Cleveland are you interested in receiving lead safety information ?
Clear selection
Are you interested in becoming a Feed the Soul Member? ( Someone from our team will contact you in regards to memberships ) *
Due to COVID-19 we offer no contact delivery to protect everyone safety, where would you like our drivers to leave your delivery? ( If you have a disability or you're unable to carry heavy weight, please make note of that so drivers know if they need to take a delivery into your home)
Thank you for taking time to complete this intake

The above questions were for intake purposes only and will only be shared with us and our partners to service you. We currently work with community leaders and stakeholders to provide several needed services and resources during this COVID-19 Pandemic and ongoing.

Please understand that all delivery services are non-contact meaning that drivers will safely sanitize and bring items to your drop off location without physically interacting with you. They will however contact you via phone for all needs and notifications.

Someone from our team will contact you to confirm your next delivery and any associated membership fees.

Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy