First Name: / Nombre: Last Name: / Apellido: Email: / Correo electrónico Mobile Phone / Teléfono móvil Address: / Dirección City: / Ciudad State: / Estado 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 American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: / Código postal - Zip Suffix Can you provide additional information to help us find your place? (For example Door on the back of the building, or apartment on the 2nd floor, etc)
¿Puede proporcionar alguna información adicional para ayudarnos a encontrar su casa? (Por ejemplo, puerta en la parte trasera del edificio, o apartamento en el segundo piso, etc.) Preferred Language / Idioma preferido How did you hear from Share My Meals?
¿Cómo se enteró de Share My Meals? From another client From someone in the community YMCA Affordable Housing Church Arm in Arm Home Front Human Services of Hospitals Housing Initiatives of Princeton (HIP) LALDEF Princeton Mobile Food Pantry The press How much money are you able to spend on food per week?
¿Cuánto puede gastar en comida a la semana? Do you currently receive food from the following organizations?
¿Recibe actualmente alimentos de las siguientes organizaciones? Other food organization Do you receive any of the following benefits? --- ¿Recibe alguna de las siguientes prestaciones? Do you have a fridge in order to keep your food fresh?
¿Tienes una nevera para mantener tus alimentos frescos? Tell us how often you need meals delivered
Díganos con qué frecuencia necesita que se le entreguen las comidas Every week Every other week Are you or an adult home between 3:30 and 5 pm to receive the meals
¿Estará usted o un adulto en su casa para recibir las comidas entre las 3:30 y las 5pm? Yes / Si No Do you have a car? / ¿Tiene coche? Yes No Do you have a smartphone where you can use WhatsApp? (This is our preferred communication channel).
¿Tienes un smartphone en el que puedas utilizar WhatsApp? (Este es nuestro canal de comunicación preferido). Yes No Which categories describe the members of your household? Mark all that apply):
¿Qué categorías describen a los miembros de su hogar? Marque todas las que correspondan): Non-Hispanic White or European American Hispanic, Latinx, or Spanish origin Black or African American Asian or Asian American South Asian or Indian American Native American Middle Eastern or North African Native Hawaiian or other Pacific Islander How many people are in your household (including yourself)?
¿Cuántas personas hay en su hogar (incluido usted)? How many people are currently employed in your household?
¿Cuántas personas trabajan actualmente en su hogar? Are any adults in the household currently unemployed and looking for work?
¿Hay algún adulto en el hogar que esté actualmente desempleado y buscando trabajo? Enter the date of birth of each member of your household:
Introduzca la fecha de nacimiento de cada miembro de su hogar: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: Enter the date of birth of each member of your household: To sign please enter your name/Para firmar, introduzca su nombre Captcha