Community Food Table Program Assessment Form

First Name *

Last Name *

Email *

Address *

City *

State

Zip *

County

Ethnicity and Race:

Total number of persons living in household:

Number of Elderly in household (62 years & older):

Number of Disabled persons in household:

Female Head of household:

Number of Children under 7 years of age:

Number of Children between 7-17 years of age:

Household Size: *

Does your house have a working stove?

Does your house have a working water?

Does your house have connection to public water?

Does your house have hot water?

Do you own or rent?

Age of House:

All information is strictly confidential. Applicants should be aware that additional questions may be asked.

Thank you for submitting your Community Food Table Program Assessment Form.

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