FeedNC · Food Movers

Food Mover Application

Has anyone in your household tested positive for COVID-19 in the last 14 days?

*

Yes

No

Name

*

First Name

Last Name

Phone Number

*

Is this a cellphone?

*

Yes

No

Email

Verify Email

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Please select the reason(s) you are applying for this service:

*

I can not leave my home because of COVID-19 outbreak.

No one in my household is able to access a grocery store.

I am unable to afford my weekly groceries.

I do not have a family member, friend, or neighbor that would be able to pick up free supplemental groceries for me.

I was recently laid off due to COVID-19 outbreak.

What is your HOUSEHOLD monthly gross income?

*

Do you use iCats (public transportation) for leisure, work, or medical appointments?

*

Yes

No

How many children are in the household under 19?

*

If you are under 19, please include yourself in the total.

How many adults between the ages of 19-64 are in the household?

*

If you are between the ages of 19-64, please include yourself in the total.

How many seniors are in the household that are 65 or older?

*

If you are 65 or older, please include yourself in the total.

How do you currently get your groceries?

*

I drive/walk to the store.

A family member or friend brings them to me.

Someone in my household gets them.

Other

If you selected other, please describe:

Do you receive Food Stamps?

*

Yes

No

Are you or anyone in your home disabled?

*

Yes

No

If you selected yes, please identify the person(s) and disability.

Does anyone in the household drive?

*

Yes

No

If you are eligible to receive free supplemental groceries from FeedNC, do you have someone that is able to pick them up for you?

*

Yes

No

Are there any pets in the home?

*

Yes

No

USDA Food Insecurity Survey

Please answer all questions honestly and to the best of your ability.

"In the last 30 days, I worried whether my food would run out before I got money to buy more".

*

"In the last 30 days, the food I bought just didn't last, and I didn't have the money to get more".

*

"In the last 30 days, I couldn't afford to eat balanced meals."

*

In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money or food?

*

If yes, how often did this happen?

*

In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

*

In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?

*

In the last 30 days, did you lose weight because there wasn't enough money for food?

*

In the last 30 days, did you or another adult in your household ever not eat for a whole day because there wasn't enough money for food?

*

If yes, How often did this happen?

*

In the last 30 days, did you ever cut the size of your child's meals because there wasn't enough money or food?

*

In the last 30 days, did any of your children ever skip meals because there wasn't enough money for food?

*

If yes, How often did this happen?

*

In the last 30 days, was your child ever hungry but you just couldn't afford more food?

*

In the last 30 days, did your child ever not eat for a while day because there wasn't enough money for food?

*

FeedNC reserves the right to use its own discretion regarding who it approves for home delivery. We also reserve the right to cancel home delivery at any time without prior notice.

How did you hear about us?

*

Applicants Signature (Please type name):

*

Date:

*