GROCERY STORE REGISTRATION

REGISTRO DE LA DESPENSA DE COMIDA

Head of Household

Name/Nombre

First Name

Last Name/Apellido

Date of Birth/Fecha de nacimiento 

Gender / género

Please select... Male Female Non-binary Prefer not to answer

Race / Raza

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Ethnicity / Etnia

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Address Line 1

City/Ciudad

State/Estado

Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau

Postal Code/Código Postal

Phone/Teléfono

Email/Correo Electrónico

Preferred Language/Idioma Preferido 

Please select... English Español Korean / 한국어 ASL

Name of proxy/person picking up groceries 

Nombre del apoderado/persona que esta recogiendo la comida

Household Information

How many live in your home/cuantos viven en tu casa 

Please select... 1 2 3 4 5 6 7 8+

I have children in DISD schools/Tengo hijos en escuelas del DISD

YesNo

Select All Benefits You Receive / Elije los beneficios que recibe

TANFChild SupportFree or Reduced Lunch at School (NSLP) / Programa Nacional de almuerzos escolaresMedicaidSNAPSocial SecuritySocial Security Income (SSI) / Seguro SocialSS DisabilityUnemploymentWICWorkers CompNone of the above / Nada

Monthly Income/Ingreso Mensual 

Please select... $0-$1,926 $1,927-$2,607 $2,608-$3,289 $3,290-$3,970 $3,971-$4,652 $4,653-$5,333 $5,334-$6,015 $6,016- $6,696 $6,697+

Others in home/Otras en la casa (1)

First Name / Nombre (1)

Last Name / apellido(1)

Relation/Relación (1)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (1)

Family Member Ethnicity / Etnia (1)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (1)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / género (1)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (1)

Others in home/Otras en la casa (2)

First Name / nombre (2)

Last Name / apellido(2)

Relation/Relación (2)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (2)

Family Member Ethnicity / Etnia (2)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (2)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender /género(2)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (2)

Others in home/Otras en la casa (3)

First Name / nombre (3)

Last Name / apellido (3)

Relation/Relación (3)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (3)

Family Member Ethnicity / Etnia (3)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (3)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / género (3)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (3)

Others in home/Otras en la casa (4)

First Name / nombre (4)

Last Name / apellido (4)

Relation/Relación (4)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (4)

Family Member Ethnicity / Etnia (4)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (4)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / género (4)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (4)

Others in home/Otras en la casa (5)

First Name / nombre (5)

Last Name / apellido (5)

Relation/Relación (5)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (5)

Family Member Ethnicity / Etnia (5)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (5)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / género (5)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (5)

Others in home/Otras en la casa (6)

First Name / nombre (6)

Last Name / apellido (6)

Relation/Relación (6)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (6)

Family Member Ethnicity / Etnia (6)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (6)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / género (6)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (6)

Others in home/Otras en la casa (7)

First Name / nombre (7)

Last Name / apellido (7)

Relation/Relación (7)

Please select... Spouse/Esposo(a) Child/Hijo(a) Other/Otra

Other relation/ Otra Relación (7)

Family Member Ethnicity / Etnia (7)

Please select... Hispanic/Latino Non-Hispanic/Non-Latino Don't know Prefer not to answer

Family member Race / Raza (7)

Please select... American Indian or Alaska Native Asian Black or African American Native Hawaiian White Two or more Pacific Islander Don't know Decline to provide

Family Member Gender / genero (7)

Please select... Female Male Non-binary Prefer not to answer

Date of Birth/Fecha de nacimiento (7)