Food Hamper Delivery Client Application

If you have any questions please call the office 250.861.5465

First name

Last name

Primary Phone

Secondary Phone

Address - Hands in Service is currently not delivering to any of the supportive housing facilities.

Email

Birthday (please note that we serve individuals below the age 65, if you are a senior, please contact Seniors Outreach)

Year

Month

Day

Other Individuals in Household (name, age, relationship to you)

Pets (List types of pet and names

Sources of Income

Disability

Social Assistance

Other

List all the agencies you receive help or support from:

If referred, Referrer's name

If referred, Referrer's phone number

What current situation is preventing you from being able to pick up your own food bank hamper?

Do you expect this situation to change in the next 6 months?

Yes

No

Do you or anyone in you household currently own a licensed vehicle?

No

Yes

If yes, please explain below

Other

I acknowledge that in order to receive this service:

I must be home on Thursdays between 10am and 2pm for delivery

I must have a working phone and be able to be contacted by call or text

If my hamper is undeliverable 3 times in a calendar year I forfeit the utilization of this service

I will update my address and phone number if it changes from the time of my first application

My eligibility will be reviewed every 6 months

Please include detailed home delivery instructions. (ie. Buzz Code, Go Through Carport, Call ahead and I'll meet you downstairs)

I, (applicant print name below) approve the release of my personal information as shown above with the understanding that this information is required to participate in the Hands in Service program or receive Hands in Service assistance and will only be provided to Hands in Service staff, volunteers or relevant health care providers as part of the Hands in Service program to ensure appropriate service delivery.

Personal Information Release

Applicant Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Please type your first & last name with today's date as an electronic signature.

Food Hamper Delivery Form