REGISTRATION

Program Registration (you only need to register one time per calendar year)

Our goal is to be a valuable resource for you and your family for as long as needed. Part of our process is to gather basic information to serve you better and share upcoming events and special distributions via email. General data (not names and contact info) is also used to secure funding to keep our services available. We cannot provide our prepared meals and grocery boxes without funding, and our funders rely on accurate information to make their giving decisions. We appreciate your participation in this process.

Name

Email (Must provide email address to be eligible for holiday distribution events)

Phone

Age

Race/Ethnicity (Use key at end of form)

Zip Code

Is this your first time receiving services, of any kind, from Women & Children’s Free Restaurant?

Yes

Number of people residing in your household (defined as you, your spouse, and dependent children)

Child 1 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 1 Race

Child 2 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 2 Race

Child 3 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 3 Race

Child 4 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 4 Race

Child 5 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 5 Race

Child 6 Age

Birth - 6 years

7 years - 12 years

13 years - 17 years

Child 6 Race

Income Information

Household Income

Income Per

How did you hear about our service?

Friend or Family

Social Media

Social Service Provider

Walk by/Drive by

School

Other

Race/Ethnicity Key
White	A person having origins in any of the original peoples of Europe, North Africa, or the Middle East.
Hispanic/Latinx	A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. Hispanics or Latinos can be of any race, ancestry, or ethnicity.
Black/African American	A person having origins in any of the black racial groups of Africa.
Asian	A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.
American Indian/Alaskan Native	A person having origins in any of the original peoples of North and South America (including Central America) and who maintains a tribal affiliation or community attachment.
Native Hawaiian/Other Pacific Islander	A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
American Indian/Alaskan Native & White	A person having these multiple racial origins as defined above.
Asian & White	A person having these multiple racial origins as defined above.
Black/African American & White	A person having these multiple racial origins as defined above.
American Indian/Alaskan Native & Black/African American	A person having these multiple racial origins as defined above.
Other Multi-Racial	Category used for reporting individual responses that are not included in any of the categories listed above.

Your privacy is important to us. Your name and contact information are confidential and will never be sold or shared with third parties.

PROGRAMS

WOMEN & CHILDREN'S FREE RESTAURANT IS A VITAL SAFETY NET THAT FILLS NUTRITIONAL GAPS FOR WOMEN AND CHILDREN IN NEED WHILE FOSTERING DIGNITY AND RESPECT, BOTH WITHIN OUR RESTAURANT AND IN THE COMMUNITY.

RESTAURANT MEALS & GROCERIES – REGISTRATION