Home Delivery Application - The Mississauga Food Bank

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Food Bank 2 Home Client Application

Use this form to apply for our home delivery program. Your application will take 3-4 business days to process, upon which the Program Coordinator will call to confirm your participation and provide further details.

Mississauga residents may access this program if they meet one of the following requirements:

You are a senior citizen aged 65+ years
You have a disability OR short/long-term illness that makes it hard to visit a food bank
You are a single, new or expecting mother (or caregiver) who is homebound

And, you do not have an adult-aged household member who is able to visit a food bank on your behalf

Please let us know your reason for applying to this program, you may refer to the eligibility criteria listed above

If applicable, please give us an estimation of when you first visited a food bank

This applies to any food bank in any city or country

Last name

First name

Date of birth

Gender

FemaleMaleTransgenderOtherUndisclosed

Marital status

SingleMarriedCommon-lawDivorcedSeparatedWidowedUndisclosed

Contact information

You must reside in Mississauga to access this program.

Address

City

Postal code

Housing type

Own homePrivate rentalSocial rental housing (subsidized housing provided through Peel Living)Emergency shelterBand owned (reserve lands)Rooming house (multi-tenant house)Group home/youth shelterStaying with family/friendsOn the streetOther

Phone number

Email address

Please provide any special instructions to reach your home, such as your buzzer number or parking instructions.

Language(s) spoken

Please list all language(s) that you speak proficiently

Which day would you prefer to receive a monthly delivery from us?

Monday (between 1:30 PM to 4:00 PM)Wednesday (between 5:30 PM to 8 PM)

Household members

Please list the number of household member(s), if any, reside in your household.

Number of children or youth (0-17 years)

Number of adults (18-64 years)

Number of seniors (65+ years)

Education

We collect this data for programming and reporting purposes. For both these purposes, the information is used in an anonymous and aggregate manner to protect your privacy.

What is the highest level of education that you have completed?

Grade 0-8Grade 9-11Grade 12Post secondary (some)Trade certificate/professional accreditationCollege diplomaUniversity degreePhDUndisclosed

Please tell us which country you completed your highest level of education in?

Monthly income

We collect this data for programming and reporting purposes. For both these purposes, the information is used in an anonymous and aggregate manner to protect your privacy.

Please select all sources of your monthly income

No incomeOntario Disability Support Program (ODSP)Ontario Works (OW)Old Age Security (OAS)Canada Pension Plan (CCP)PensionsEmployment Insurance (EI)Workplace Safety & Insurance Board (WSIB)Spouse/Family supportEmployed: Full timeEmployed: Part-timeChild supportChild tax benefitScholarshipStudent loansUniversal Child BenefitOther

Please provide an estimate of your total monthly income

Please provide an estimate of your total monthly household expenses

Such as rent/mortgage, utilities, phone, internet, vehicle, insurance, childcare, child support, debt payments, food, medical, personal, or transit expenses

Dietary considerations

What, if any, dietary needs do you have?

DiabeticFish onlyHalalKosherMilk allergyNo porkPeanut allergyEgg allergyPregnantSeafood allergySesame allergyVeganVegetarianWheat allergyOther

Please provide any additional dietary information

Emergency contact

Full name

Phone number

Contact Information

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Copyright © 2019 The Mississauga Food Bank. All Rights Reserved.

The Mississauga Food Bank is a federally registered charitable organization: 11892 7011 RR0001. We acknowledge that The Mississauga Food Bank is located on the Treaty Lands and Territory of the Mississaugas of the Credit First Nation.

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