CalFresh Intake Form

CalFresh Intake Form

Please complete the following intake form so that one of our staff members can contact you and further assist you with all questions regarding CalFresh.

CalFresh Intake Form

Name

First Name *

Last Name *

Phone Number (Required)

Your Email

Income Source

None
Wages
SSI
SSA
SDI
Unemployment
Other

Expense Sources

None
Rent
Medical
Child/Adult Care

Gender

Male
Female
Other
Prefer not to say

Primary Language (Required)

Household Size (Required)

Number of Children (Required)

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Seniors in household?

Students in household?

If you are using Internet Explorer, this form may not work. Please try opening in a different browser. If you still cannot complete the form, please call us at (707) 523-7903.

Diaper Bank

The Redwood Empire Food Bank has officially become a member of the National Diaper Bank Network (NDBN) and is the designated Diaper Bank for Sonoma, Lake, Mendocino, Humboldt, and Del Norte counties. Families are offered 50 diapers per month for children ages 0-4 years old.

CalFresh Intake Form

CalFresh Intake Form

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CalFresh Intake Form

Diaper Bank