Registration Registration Form Step 1 of 3 33% Full Name* First Last Date of Birth* Month Day Year Gender*FemaleMaleGender DiverseEmail Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Why is this information required?Sharing Life receives food from many sources including various government programs. Sharing Life must gather limited information from our clients to ensure we stay compliant with their requirements to continue to receive food to share with our community. Sharing Life also uses your information to determine the level of services your household is eligible to receive in our program. We never sell any information that we collect.Race*American Indian / Alaska NativeAsianBlack / African AmericanNative Hawaiian / Pacific IslanderWhiteOtherI do not wish to answerEthnicityHispanic / LatinoNon-Hispanic / Non-LatinoI do not wish to answerMonthly Household Income*How many people live in your household?*PAN Eligible?*Do you currently receive PAN/CSFP benefits? Yes No List of Household members*First NameLast NameGenderDate of BirthRelationshipReceives PAN FemaleMaleGender DiverseNoYes Are you receiving any of the following assistance?* SNAP TNAF Child Support WIC Work. Comp Unemployment Social Security SS Disability SSI N/A Please check all that apply. CertificationBy signing below, I certify that: (1) I am a member of the household living at the address provided in Section 1 and that, on behalf of the household, I apply for USDA Foods that are distributed through The Emergency Food Assistance Program; (2) all information provided to the agency determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and (3) if applicable, the information provided by the household’s proxy is, to the best of my knowledge and belief, true and correct.SignatureUSDA DisclaimerIn accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: https://www.usda.gov/oascr/how-to-file-a-program-discrimination-complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected] This institution is an equal opportunity provider.