Loaves & Fishes Card Registration

Loaves & Fishes is providing online registration. After filling out the form below, a Loaves & Fishes representative will call to confirm.

Name*
First Last
Birthday*
Month
Day
Year

Month/Day/Year
What is your gender?*
- Male
- Female
- Non-binary/another gender
- Prefer not to answer
Please select one of the above
What best describes your race?*
- Asian
- Black or African American
- Hispanic or Latino/a/x
- Middle Eastern or North African
- Pacific Islander or Native Hawaiian
- White
- Another race
- Prefer not to answer
What is your preferred language?*
Address*
Street Address Apt# City ZIP / Postal Code
What county do you live in?*
Phone*
Email

Your temporary ID card will be sent to this email.
Total number of household members*

Household Information*

First Name	Last Name	Birthday	Relationship	Gender	Race

In the fields above, please list any additional people who live in your household, their birthday, and their relationship to you, the registrant.

Number of children 18 or younger*
What is your monthly gross household income?*
Are you currently employed?*
- Yes
- No
Are you using SNAP/LINK card?*
- Yes
- No
Are you a veteran?*
- Yes
- No
Is there anything else you would like for us to know?
Loaves & Fishes Distribution Conditions*
By checking this box, you agree to the Loaves & Fishes conditions
1. I accept the food and supplies donated to me, understanding that these items are for the use of my household needs.

2. I accept these donated items as a “Good Samaritan Act” and agree to hold harmless Loaves & Fishes Community Services staff, volunteers, and suppliers of the pantry.

3. I understand that not giving complete information can limit access to all Loaves & Fishes programs.

4. I consent that the information provided to Loaves & Fishes may be confidentially shared with partner agencies to better understand the need in our community and the impact of our services. No personally identifying information is shared.

5. I consent to these conditions today and each time I receive a food distribution.