December 6th: Evergreen Valley College Food Distribution
Please note:
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity.

The Evergreen Valley College & Second Harvest Food Distribution will take place the FIRST and THIRD Friday of the month between 9:30 am-11:00 am inside of EVC Parking Lot 1.


This form MUST be completed for every food distribution in which you wish to receive items.

PLEASE NOTE:
All individuals arriving at the EVC campus MUST wear a face mask.  

By submitting this form you self declare that:
1. Your name and address listed is correct, if homeless, you can put homeless as an address.
2. Your household size as stated and resides within the state and organization's service area.
3. Your income is within 235% of the Federal Poverty Guidelines as posted for this distribution.
4. You agree that TEFAP food is for home consumption only and will not be sold, traded, or bartered.
5. You have been shown and have read the full USDA Nondiscrimination Statement:
           https://www.fns.usda.gov/usda-nondiscrimination-statement


Remember, You will not be denied TEFAP food if you refuse to disclose any information that is not a requirement of TEFAP. You will never need to provide your social security number or proof of income.

Questions or concerns? Email mailto:america.minjares@evc.edu. 
Vietnamese translation available upon request.

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Evergreen Valley College Drive-Thru Food Distribution Registration Form
What is your first name? *
What is your last name? *
What is your SJECCD Student ID Number? If you are a community member, please write "community member" *
What is your date of birth?
MM
/
DD
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YYYY
What is your phone number? Please type your phone number in the following format xxx-xxx-xxxx
May we text you with updates regarding the Food Distribution?
Clear selection
What is your home address? Please include the full street, city, and zip code (for example: 3095 Yerba Buena Road, San Jose, CA 95135) *
What is your preferred language?
Clear selection
Please list the approximate number of family members within your household between the ages of 0-17 (for example if there are children aged 13 and 8 you would write 2, in none write 0) *
Please list the approximate number of family members within your household between the ages of 18-60, if none write 0 *
Please list the approximate number of family members within your household 61 years of age or older, if none write 0 *
Have you received food from a Second Harvest Food Distribution before? *
Is this your first time receiving USDA food this month? *
What is your email? (please double check before submitting. In order to receive a link to select your appointment time, your email is needed) *
Submit
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