Mitzvah Food Program Recipient Intake Form

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).

Basic Information
Today's Date*
MM slash DD slash YYYY
Choose One Pantry Location*
- 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*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Cell Phone (if different than above)
Email
What is the best way to contact you?
- Email
- Phone
Do you need delivery?*
- Yes
- No
Why are you requesting the delivery option?*

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?*
- English
- Russian
- Spanish
- French
- Creole
- Haitian
- African Language
- Arabic
- Cambodian
- Chinese
- Czechoslovakian
- German
- Hebrew
- Hindi
- Hungarian
- Italian
- Japanese
- Korean
- Other Asian
- Other European
- Polish
- Portuguese
- Ukrainian
- Vietnamese
- Yiddish
Religious Affiliation*
- Jewish
- Buddhist
- Christian
- Episcopal
- Evangelical
- Catholic
- Jehovah’s Witness
- Baptist
- Lutheran
- Methodist
- Mormon
- Presbyterian
- Pentecostal
- Seventh-day Adventist
- Russian Orthodox
- Unknown
- Muslim
- Hindu
- Atheist
- Agnostic
- None
- Other
- Prefer not to answer
Do you have Jewish Heritage?*
- Yes
- No
Are you or is someone in your house a Holocaust survivor?*
- Yes
- No
Do you live in subsidized housing?*
- Yes
- No
Dietary Information
Do you keep kosher?*
- Yes
- No
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
- No
Are you willing to receive vegetarian food items that may not bear explicit Kosher certification?*
- Yes
- No
Does someone in your house have special dietary needs?*
- None
- Low Salt
- Low Sugar
- Celiac (Gluten Free)
- Lactose Intolerant
- Nut Allergy
Household Income Information
Total number of people in your household, including yourself.*
Total monthly/annual income for your whole household.*
Household Benefit Information
Is your household receiving Food Stamps (SNAP)?*
- Yes
- No
If you do receive SNAP dollars, how much do you receive monthly?
Which of the following benefits is your household receiving?
- Energy Assistance (LIHEAP)
- TANF (Temporary Assistance for Needy Families)
- SSI (Supplemental Security Income)
- SSD (Supplemental Security Disability)
- Medicaid
- PACE/PACENET
- Unemployment
- Earned Income Tax Credit (EITC)
- Property Tax/Rent Rebate (PT/RR)
- Services from JFCS (Jewish Family and Children’s Service)
- Food packages from the Jewish Relief Agency (Food Box)
- Food deliveries from KleinLife (Cook for a Friend/Meals on Wheels)
- Attends lunch program at KleinLife in Center City or Northeast (you or a member of your household)
Would you like to speak with a Social Worker about public benefits or community resources?*
- Yes
- No
What is your health insurance plan / provider?*
- 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*
First Last
Date of Birth or Age*
Are you a U.S. Military Veteran?*
- Yes
- No
Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?*
- Yes
- No
Gender:*
- Male
- Female
- Trans Man
- Trans Woman
- Non-binary
Work Status*
- Employed – Full Time
- Employed – Part Time
- Unemployed – Looking for Work
- Unemployed – Not Looking for Work
- Military
- Retired
- Disabled
- Child (under 18)
- Student (College or Grad)
- Unknown
Citizenship Status*
- US Citizen
- Green Card / Permanent Resident
- Immigrants
- Refugees/Asylees
- Other
Race*
- Caucasian
- African-American
- Asian
- Hispanic
- Multi-Racial
- Hawaiian or Pacific Islander
- Indian
- Middle Eastern
- Native American
- Unknown
- Other
Relationship to Head of Household*
Person 2
Name Of Person 2*
First Last
Date of Birth or Age*
Are you a U.S. Military Veteran?*
- Yes
- No
Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?*
- Yes
- No
Gender:*
- Male
- Female
- Trans Man
- Trans Woman
- Non-binary
Work Status*
- Employed – Full Time
- Employed – Part Time
- Unemployed – Looking for Work
- Unemployed – Not Looking for Work
- Military
- Retired
- Disabled
- Child (under 18)
- Student (College or Grad)
- Unknown
Citizenship Status*
- US Citizen
- Green Card / Permanent Resident
- Immigrants
- Refugees/Asylees
- Other
Race*
- Caucasian
- African-American
- Asian
- Hispanic
- Multi-Racial
- Hawaiian or Pacific Islander
- Indian
- Middle Eastern
- Native American
- Unknown
- Other
Relationship to Head of Household*
Person 3
Name of Person 3*
First Last
Date of Birth or Age*
Are you a U.S. Military Veteran?*
- Yes
- No
Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?*
- Yes
- No
Gender:*
- Male
- Female
- Trans Man
- Trans Woman
- Non-binary
Work Status*
- Employed – Full Time
- Employed – Part Time
- Unemployed – Looking for Work
- Unemployed – Not Looking for Work
- Military
- Retired
- Disabled
- Child (under 18)
- Student (College or Grad)
- Unknown
Citizenship Status*
- US Citizen
- Green Card / Permanent Resident
- Immigrants
- Refugees/Asylees
- Other
Race*
- Caucasian
- African-American
- Asian
- Hispanic
- Multi-Racial
- Hawaiian or Pacific Islander
- Indian
- Middle Eastern
- Native American
- Unknown
- Other
Relationship to Head of Household*
Person 4
Name of Person 4*
First Last
Date of Birth or Age*
Are you a U.S. Military Veteran?*
- Yes
- No
Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?*
- Yes
- No
Gender:*
- Male
- Female
- Trans Man
- Trans Woman
- Non-binary
Work Status*
- Employed – Full Time
- Employed – Part Time
- Unemployed – Looking for Work
- Unemployed – Not Looking for Work
- Military
- Retired
- Disabled
- Child (under 18)
- Student (College or Grad)
- Unknown
Citizenship Status*
- US Citizen
- Green Card / Permanent Resident
- Immigrants
- Refugees/Asylees
- Other
Race*
- Caucasian
- African-American
- Asian
- Hispanic
- Multi-Racial
- Hawaiian or Pacific Islander
- Indian
- Middle Eastern
- Native American
- Unknown
- Other
Relationship to Head of Household*
Person 5
Name of Person 5*
First Last
Date of Birth or Age*
Are you a U.S. Military Veteran?*
- Yes
- No
Do you identify as LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?*
- Yes
- No
Gender:*
- Male
- Female
- Trans Man
- Trans Woman
- Non-binary
Work Status*
- Employed – Full Time
- Employed – Part Time
- Unemployed – Looking for Work
- Unemployed – Not Looking for Work
- Military
- Retired
- Disabled
- Child (under 18)
- Student (College or Grad)
- Unknown
Citizenship Status*
- US Citizen
- Green Card / Permanent Resident
- Immigrants
- Refugees/Asylees
- Other
Race*
- Caucasian
- African-American
- Asian
- Hispanic
- Multi-Racial
- Hawaiian or Pacific Islander
- Indian
- Middle Eastern
- Native American
- Unknown
- Other
Relationship to Head of Household*
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?*
- Friend
- Family Member
- Internet Search
- Neighbor
- Philabundance
- Religious Institution/Leader
- Social Worker
Social Worker Organization*
Social Worker Full Name*
Social Worker Email*
Social Worker Phone Number*
How many food pantries (including this one) do you visit a month?*
- 1
- 2
- 3
- 4
- More
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?*
- 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?*
- 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?*
- Yes
- No
- 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?*
- 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?*
- Yes
- No
- 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?*
- Yes
- No
- 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

Basic Information

Dietary Information

Household Income Information

Household Benefit Information

Members of Household Information

Person 1 (You)

Person 2

Person 3

Person 4

Person 5

Additional Information

U.S. Household Food Security Survey Module

CONTACT INFORMATION