Dine-in 2 Participant Waitlist Eligibility Questionnaire
Please provide responses to the following questions so that we may determine eligibility.
Untitled Title
First Name *
Last Name *
Phone Number *
Email
Do you prefer to be contacted by email, phone or text? *
Required
Address
City
Zip Code
Gender
Clear selection
Age Range
Clear selection
Race
Have you received any of the following resources? (This will not make you ineligible)
How many people are in your household?
Clear selection
My household consists of: *
Required
What is your annual salary?
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Do you have dietary restrictions? *
If you answered yes, to the question above, what are your dietary requirements?
Are you experiencing a hardship for any of these reasons? Please check all that apply.
Have your needs been met for this current month? *
What other resources are you in need of?
Are you able to pick up your meals?
Clear selection
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This form was created inside of GS NAACP.