CCEFS Service Registration
CCEFS is required to collect this information once per year for our federal program reporting. We will keep your data confidential. For more information on your data privacy, click here: https://ccefs.org/wp-content/uploads/2021/10/Data-Privacy-Discrimination-2021.pdf

Once complete, this form is good until July. Households are required to self-disclose income, household size, or address changes that may affect their eligibility.

Please provide information for the primary household member - the person most likely to be coming to pick up food for your household. If someone else in the household comes to pick up food, it is most helpful if they provide the name or phone number of the primary household member.
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First Name(s) *
Last Name(s) *
Street Address *
City *
Zip Code *
Number of Children in Household ages (0-17): *
Number of Adults in Household ages (18-64): *
Number of Seniors in Household (65+): *
Is your monthly household income at or below the guidelines shown below? *
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Telephone number (optional)
By providing the phone number of the primary household member who will pick up food, we can use that number to quickly pull up your household information for future visits.
Email (0ptional)
If you would like to receive our emails, please list your email address here. We send out notices about special distributions/events and a monthly e-newsletter with resources and information.
Signature *
By typing your name below you indicate that all information above is accurate to the best of your knowledge.
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