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Dine-in 2 Participant Waitlist Eligibility Questionnaire
Please provide responses to the following questions so that we may determine eligibility.
* Indicates required question
Untitled Title
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email
Your answer
Do you prefer to be contacted by email, phone or text?
*
Email
Phone
Text
Required
Address
Your answer
City
Your answer
Zip Code
Your answer
Gender
Male
Female
Non-Binary
Decline to State
Clear selection
Age Range
18-25
26-35
36-55
55-65
65+
Clear selection
Race
White
Black or African American
Latino
Asian/Pacific Islander
Hawaiin/Pacific Island
Native American/Alaskan Native
Other
Have you received any of the following resources? (This will not make you ineligible)
CalFresh
WIC
Rent Relief
Utility Relief
Food Bank/Food Closet
Section 8
How many people are in your household?
1
2
3
4
5
6
7
8
9
10
Clear selection
My household consists of:
*
Spouse
Dependents
Roommates
Self
Required
What is your annual salary?
$12,880 or less
$12,881 - $17, 420
$17,421 - $21,959
$21,960 - $26,449
$26,500 - $31,039
$31,040 - $35,579
$35,580 - $40,119
$40,120 - $44,660
Other:
Clear selection
Do you have dietary restrictions?
*
Yes
No
If you answered yes, to the question above, what are your dietary requirements?
Low-sodium
Low Fat
Low Glycemic
Gluten Free
Are you experiencing a hardship for any of these reasons? Please check all that apply.
Cost of living - increased rent
Increase in gas prices
Unable to catch up on bills accumulated due to COVID-19
Homeless
Have your needs been met for this current month?
*
Yes
No
What other resources are you in need of?
Housing
Food
Utility Assistance
Water Bills
Health Care
Are you able to pick up your meals?
Yes
No
Maybe
Clear selection
Submit
Clear form
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