Contact Information

First Name

Last Name

Email Address

Street Address

City

US State

Zip/Postal Code

Government Assistance

Do you currently receive any form of government assistance? (This information better helps us understand your needs, but will not affect your eligibility for our program.)

YesNo

If yes, please specify the type(s) of assistance (e.g. SNAP, Medicaid, Housing Vouchers, etc.):

Confidentiality, Use of Information, and Program Eligibility:

Information collected will be used for grant applications to support the cost of the Cutting Costs Program. Individual information will not be shared and does not impact your eligibility.

Annual Household Income:

Please select the range that corresponds to your annual household income before taxes. Refer to the most recent tax year.

Please read each of the following statements and select the most applicable answer.
(When considering these questions, please keep in mind the last 12 months specifically.)

The food that I bought just didn't last, and I don't have money to get more.

Often trueSometimes trueNever trueDon't know

I can't afford to eat balanced meals.

Often trueSometimes trueNever trueDon't know

I have had to cut down the size of my meals or skip meals because there wasn't enough money for food.

Often trueSometimes trueNever trueDon't know

There have been times in the past year when I found it challenging to afford gluten-free food options, leading me to consume foods containing gluten.

Often trueSometimes trueNever trueDon't know

Medical information:

Were you referred to this program by a medical professional?

YesNo

If yes, please provide the name and contact information of the referring professional (optional):

First Name

Last Name

Email Address

Phone Number

Consent and Agree:

I consent and agree to the collection and use of my personal, demographic, and financial information. I understand that GIG Cares will use this confidential information to assess my application for the program, to tailor the program to the needs of its participants, and to secure grants and funding to support the program. I acknowledge that my participation is voluntary, and I have the right to withdraw my application at any time.

I consent and agree