R&R Highline Foods

Applicant Information

Member's First Name *

Member's Last Name *

Date of Birth *

CIN *

Medicaid ID#: 2 letters, 5 numbers, and another letter. Found on your Medicaid or insurance card.

Phone Number *

Text Message Preferences

Would you like to receive text messages from R&R Highline Foods about your application, customer support, and food delivery updates, including tracking links?

Yes No

Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for help. Consent is not required to submit this application. See our Privacy Policy and SMS Terms and Conditions.

Home Address *

City, State and Zip *

Email Address *

Household

Additional Household Members *

WITHOUT THIS INFORMATION YOUR APPLICATION WILL NOT BE PROCESSED. List all household members’ legal name, CIN numbers (2 letters, 5 digits, then 1 letter), dates of birth, and relationship to applicant.

Is this a transfer? *

Yes No

Comments

Please submit one household application unless instructed otherwise.

Submitting this application does not guarantee approval. Eligibility depends on Medicaid enrollment, program screening, food-support need, and other Social Care Network requirements.

Food Box Application

Applicant Information

Housing & Living Situation

Benefits & Support

Health

Food & Nutrition

Household