3rdstrEATS Referral Form
We are asking new referrals to pick up their bags at the 3rd Street Youth Clinic location between 12-4pm on Wednesdays.
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First and Last Name
I identify my ethnicity/race as: (Select all that apply)
Middle Eastern / North African
Hispanic /Latinx / Spanish Origin
Pacific Islander / Native Hawaiian
Gender & Pronouns
Address and Zip Code (for when we have delivery drivers available to deliver groceries to your house)
Number of people in your household
Who referred you to the program?
Through Virtual Workshop/Webinar
Thanks for submitting!
Our Outreach Coordinator at 3rdstrEATS will contact you soon!
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This form was created inside of 3rd Street Youth Center & Clinic.