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We are glad you found our Blessing box
Please complete so we can continue to help you.
1. Household Makeup/Maquillaje para el hogar:
#Adults/Adultos:
#Children/Niños:
2.Race/Raza-Ethnicity
White/Blanco
Black/Negro
Hispanic
Other
3. Are you? (Check all that apply)
A Senior Citizen
Disabled
Homeless
A Veteran:
4.Are you Employed
FT
PT
Retired
5.Do you receive Food Stamps?/Recibes cupones de alimentos?
Yes
No
6. Zip Code/Código postal:
7. Did this box help meet your needs? / Esta caja le ayudo a satisfacer sus necesidades ?
Yes
No
If No how can we meet your needs?/Si No, Como?
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