CKSCORP Intake Form COMMUNITY KITCHEN SERVICES CORP FOOD ASSISTANCE PROGRAM CLIENT INTAKE FORM Head of Household Information First Name * Last Name * Date of Birth * Street Address * Apt # City Zip Code * Demographic information below is not required to receive food. Phone Number () – Home Work Cell Email Gross Household Income $ Weekly Bi-weekly Monthly Yearly Gender Female Male Ethnicity African American/Black Native American/Native Alaskan Asian Native Hawaiian/Pacific Islander Caucasian/White Other Hispanic/Latino (a) Decline to State Primary Language Creole Spanish Other Additional Questions Veteran Yes No Disabled Yes No Homeless Yes No Active Military/Dependent Yes No Household Public Benefits Disability EBT Social Security Medicare/Medicaid # of Living Household Household Members List * First Name * Last Name * Date of Birth * Gender Ethnicity Relationship * + Add Member I have read the CKSCORP authorization and agree to the terms. Signature (Type Full Name) Date SUBMIT FORM
