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UHD Food Market
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Full Name (First & Last)
*
Birthdate (mm/dd/yyyy)
*
How many pounds of dry goods do you have today?
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How many pounds of produce do you have today?
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Student ID Number
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What is your FFC #
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Check off all items that you have included in your groceries today:
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Dry Food
Canned Food
Frozen Items
Protein
Drinks
Refrigerated Items
Other
Would you be interested in someone contacting you about your eligibility and application assistance for Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF) cash benefits
Children’s Medicaid
Children’s Health Insurance Program (CHIP)
Women’s Health Program (Family Planning, Health screenings thru Medicaid Program)
CHIP Perinatal Program
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Yes
No
Have ideas, feedback, or comments? Let us know!
Thank you for your input! Come back to the UHD Food Market anytime for your weekly 60 pounds of free food! Tell your friends about us!
