Beacon Light Second Harvest Food Pantry Registration Form
Please complete the following form to complete the initial registration process to receive commodities from the Second Harvest Food Pantry at Beacon Light International Baptist Cathedral. Upon check-in at the first attended distribution, all new clients must provide the items listed below to complete the certification process. All clients are required to re-certify in July of every year. 

1.) Valid ID or Driver's License

2.) Valid Proof of Residence, such as a utility bill or rental/ lease agreement, with the applicant's name and current address (Orleans Parish only)

3.) Valid, Current Household Income Information


Thank you for allowing us to serve you! May God bless you and yours!
Sign in to Google to save your progress. Learn more
First Name *
Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Race/ Ethnicity *
Please select all that apply.
Required
Street Address *
City *
State *
Zip Code *
Email Address
Mobile Phone Number *
Would you be interested in receiving text or email updates, such as reminders about food distribution dates? *
Required
How many people in your household, not including yourself, will benefit from our services?
Date of Birth/ Age Information for Household Members
Please use the space below to indicate the date of birth or age information for each member of your household, not including yourself, who will benefit from our services.
Would anyone outside your household pick up your commodities if you are unavailable? *
First Name of Authorized Pick-Up Representative 1
Last Name of Authorized Pick-Up Representative 1
Mobile Phone Number of Authorized Pick-Up Representative 1
First Name of Authorized Pick-Up Representative 2
Last Name of Authorized Pick-Up Representative 2
Mobile Phone Number of Authorized Pick-Up Representative 2
First Name of Authorized Pick-Up Representative 3
Last Name of Authorized Pick-Up Representative 3
Mobile Phone Number of Authorized Pick-Up Representative 3
Is anyone in your household currently receiving SNAP or Food Stamps? *
Does anyone in your household currently receive benefits through the following government programs?
 *
Required
What is your total monthly gross household income?
 *
Questions or Comments
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms