Mitzvah Food Program Recipient Intake Form – Jewish Federation of Greater Philadelphia

This form is not mandatory to receive food in person. This information is confidential and will not affect your eligibility for food. Every question must be answered clearly (N/A, none, or 0 if your answer does not apply). Our four pantries distribute nutritious food too all who are in need, regardless of race, income, gender, age, or religion.

Basic Information

Today's Date(Required)

Choose One Pantry Location(Required)

Old York Road (Beth Sholom Congregation)

Lower Bucks County (Congregation Tifereth Israel)

Northeast (KleinLife)

Mainline (JFCS Brodsky Building)

I don’t know which one to choose/help me decide

Click here for more information about the pantry sites.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone(Required)

Cell Phone (if different than above)

What is the best way to contact you?

Phone

Do you need delivery?(Required)

Yes

Why are you requesting the delivery option?(Required)

This is a mandatory field if you answered that you do need delivery. For example: You are home-bound, disabled, or ill. Please note that it may take time to place you on a delivery route as we depend on volunteers to deliver to you.

What is your primary language?(Required)

Religious Affiliation(Required)

Do you have Jewish Heritage?(Required)

Yes

Are you or is someone in your house a Holocaust survivor?(Required)

Yes

Do you live in subsidized housing?(Required)

Yes

Dietary Information

Do you keep kosher?(Required)

Yes

Kosher designates food that satisfies the requirements of Jewish law. This means, in short, that no meat and dairy can be consumed together, no shellfish (including lobster and shrimp), and no pork may be eaten. Also, in order to be Kosher, Kosher animals must be butchered in a specific way that satisfies the requirements of Jewish law.

If you keep Kosher, do you keep to "Orthodox Union" (OU) standards or higher?

Yes

Are you willing to receive vegetarian food items that may not bear explicit Kosher certification?(Required)

Yes

Does someone in your house have special dietary needs?(Required)

None

Low Salt

Low Sugar

Celiac (Gluten Free)

Lactose Intolerant

Nut Allergy

Household Income Information

Total number of people in your household, including yourself.(Required)

Total monthly/annual income for your whole household.(Required)

Household Benefit Information

Is your household receiving Food Stamps (SNAP)?(Required)

Yes

If you do receive SNAP dollars, how much do you receive monthly?

Which of the following benefits is your household receiving?

Would you like to speak with a Social Worker about public benefits or community resources?(Required)

Yes

What is your health insurance plan / provider?(Required)

Aetna Better Health

Blue Cross Keystone First

Cigna Healthcare

Health Partners

Medicaid

Medicare

United Healthcare

Other

If other, please specify.

Members of Household Information

Please fill out the information below for every person in your household including yourself.

Person 1 (You)

Name(Required)

First Last

Date of Birth or Age(Required)

Are you a U.S. Military Veteran?(Required)

Yes

Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?(Required)

Yes

Gender:(Required)

Work Status(Required)

Citizenship Status(Required)

US Citizen

Green Card / Permanent Resident

Immigrants

Refugees/Asylees

Other

Race(Required)

Relationship to Head of Household(Required)

Person 2

Name Of Person 2(Required)

First Last

Date of Birth or Age(Required)

Are you a U.S. Military Veteran?(Required)

Yes

Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?(Required)

Yes

Gender:(Required)

Work Status(Required)

Citizenship Status(Required)

US Citizen

Green Card / Permanent Resident

Immigrants

Refugees/Asylees

Other

Race(Required)

Relationship to Head of Household(Required)

Person 3

Name of Person 3(Required)

First Last

Date of Birth or Age(Required)

Are you a U.S. Military Veteran?(Required)

Yes

Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?(Required)

Yes

Gender:(Required)

Work Status(Required)

Citizenship Status(Required)

US Citizen

Green Card / Permanent Resident

Immigrants

Refugees/Asylees

Other

Race(Required)

Relationship to Head of Household(Required)

Person 4

Name of Person 4(Required)

First Last

Date of Birth or Age(Required)

Are you a U.S. Military Veteran?(Required)

Yes

Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?(Required)

Yes

Gender:(Required)

Work Status(Required)

Citizenship Status(Required)

US Citizen

Green Card / Permanent Resident

Immigrants

Refugees/Asylees

Other

Race(Required)

Relationship to Head of Household(Required)

Person 5

Name of Person 5(Required)

First Last

Date of Birth or Age(Required)

Are you a U.S. Military Veteran?(Required)

Yes

Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?(Required)

Yes

Gender:(Required)

Work Status(Required)

Citizenship Status(Required)

US Citizen

Green Card / Permanent Resident

Immigrants

Refugees/Asylees

Other

Race(Required)

Relationship to Head of Household(Required)

If there are more than 5 members of your household, please list them with all their pertinent information here.

Additional Information

How did you hear about the Mitzvah Food Program?(Required)

Friend

Family Member

Internet Search

Neighbor

Philabundance

Religious Institution/Leader

Social Worker

Social Worker Organization(Required)

Social Worker Full Name(Required)

Social Worker Email(Required)

Social Worker Phone Number(Required)

How many food pantries (including this one) do you visit a month?(Required)

U.S. Household Food Security Survey Module

Six-Item Short Form Economic Research Service, USDA — These next questions are about the food eaten in your household in the last 12 months and whether you were able to afford the food you need.

“The food that (I/we) bought just didn’t last, and (I/we) didn’t have money to get more.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?(Required)

Often True

Sometimes True

Never True

Don’t Know / Refuse

“(I/we) couldn’t afford to eat balanced meals.” Was that often, sometimes, or never true for (you/your household) in the last 12 months?(Required)

Often True

Sometimes True

Never True

Don’t Know / Refuse

In the last 12 months, did (you/you or other adults in your household) ever cut the size of your meals or skip meals because there wasn't enough money for food?(Required)

Yes

Don’t Know / Refuse

How often did this happen—almost every month, some months but not every month, or in only 1 or 2 months?(Required)

Almost every month

Some months

Only 1 or 2 months

Don’t Know

In the last 12 months, did you ever eat less than you felt you should because there wasn't enough money for food?(Required)

Yes

Don’t Know / Refuse

In the last 12 months, were you ever hungry but didn't eat because there wasn't enough money for food?(Required)

Yes

Don’t Know / Refuse

SERVING VULNERABLE POPULATIONS

We meet the most basic needs of community members locally, in Israel and throughout the world.

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CONTACT INFORMATION

mitzvahfoodprogram@jewishphilly.org
215.832.0509