Dine-in 2 Participant Waitlist Eligibility Questionnaire
Please provide responses to the following questions so that we may determine eligibility.
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First Name *
Last Name *
Phone Number *
Do you prefer to be contacted by email, phone or text? *
Zip Code
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Age Range
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Have you received any of the following resources? (This will not make you ineligible)
How many people are in your household?
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My household consists of: *
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?
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This form was created inside of GS NAACP.