FRESH FOOD DELIVERY REQUEST
Please provide your information so that we can place you on the roster for Fresh Food Delivery.  The program manager will contact you with further details.  
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Email *
What is today's date?
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Do you currently receive services from Disability Network of Wayne County Detroit *
What is the Full Name on your Identification.  First,  Middle, and Last Name? *
Please enter your name information:
If you live in a Senior Building, please select what Senior Building you live in or the Senior Program you belong to:
What is your mailing address where you want the food box delivered?  If you live at a senior building, please give your apartment/floor/location.
What is your current telephone number? or the Name and Phone Number of your Caregiver? *
What is your email address?
Do you self-report that you are 60 years old or older?
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What County do you live in? *
Required
Are you currently receiving a food box from Focus Hope? *
What type of program are you enrolled in to make you eligible for the Fresh Food Delivery? *
Required
Do you self report that your household income is $1,473.00 or lower? *
Do you have an assigned DNWCD staff working with you with other disability services? If so, what is their name?
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