Vulnerability Assessment for Food/Supply
We will review your information to determine if you qualify for assistance. A family liaison will be in contact with you if more information is needed. Thank you.
Parent/Guardian Full Name
Please list the names of your students and where they attend school
Phone or Email
Address (if you are homeless, please enter 'n/a')
How many people live in your household?
Are you experiencing housing instability, living doubled up with family/ friends, moving frequently, facing eviction, living in substandard housing, or experiencing immigration challenges?
Is your family eligible to receive a government stimulus check?
No, we will not receive a government stimulus check
I'm not sure
Do you receive EBT Food Benefits every month?
Which statement best describes your current need of food?
I need food As Soon As Possible. This is an emergency.
I have enough food but need help in a week or two.
I do not need extra food.
Which statement best describes your current need for household supplies?
I need supplies As Soon As Possible. This is an emergency.
I have enough supplies but need help in a week or two.
I do not need extra household supplies
Select all SUPPLY items you need most:
Select all FOOD items you need most.
dry beans (black, pinto)
canned vegetables etc.
fresh fruit & vegetables
I CANNOT REFRIGERATE FOOD
How often does this Family need food/supply assistance?
Every other week
Once a month
Just one time
Is there anything else you want us to know?
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This form was created inside of Shelton School District.