Dining Site Registration Form

"*" indicates required fields

Participant Name*
Participant Address*
Live Alone
Sexual Orientation
Do you consider yourself to be transgender or gender non-conforming
Emergency Contact Name
Participant Speaks English
Participant Speaks Other Language in Home?
Household Size?
Is annual income below the poverty level?
$13,590 (household of 1) | $18,310 (household of 2)

Nutrition Risk

Select All That Apply

Staff Use

I understand that the confidential information I am providing on this form will be used for state and federal reporting requirements, program management, quality assurance, public safety and research. No other use of personal identifying information on th is form is intended unless I authorize it or a court orders it.
Registration Type (All of these clients qualify at the donation rate)