District 5 Free Grocery Store Shopper Waitlist Form
Councilwoman Shayla Adams-Stafford is excited to announce that a free community grocery store is OPEN to District 5 as of May 28, 2026. This store will be located in the Fairmount Heights Branch Library and will allow 175 families the opportunity to shop up once per month for a bag of grocery items. 

If you are interested in being added to the shopper waitlist and or volunteering, please complete this form in its entirety. Please review your information to ensure it is recorded correctly. 
NOTE: Your personal information will be kept confidential.

If you are selected as one of the families, you will be notified via email, and a phone call as we are able to move individuals off the waitlist!

For any questions regarding this event please contact our office at pgcdistrict5sp@gmail.com or call (301) 780-8285.
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Do you want to volunteer, be added to the shopper waitlist, or both? *
Last Name *
First Name *
Email Address *
Phone Number *
Home Address (For District Verification) *
Select your neighborhood. *
What is your date of birth?  *
MM
/
DD
/
YYYY
Which designation(s) describes you? Select all that apply. *
Required
What is your primary language? *
OPTIONAL: How many individuals live in your home (including yourself)?
Are you employed? *
OPTIONAL: What is your source(s) of income?
What is your primary mode of transportation? *
OPTIONAL: Do you currently receive SNAP, TANF, or WIC benefits?
Clear selection
OPTIONAL: What is your monthly grocery bill, on average?
OPTIONAL: In the last 3 months, have you needed assistance with housing expenses or groceries?
Clear selection
Who referred you to apply? 
Clear selection
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