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 *

Home Address *

City, State and Zip *

Email Address *

Housing & Living Situation

What is your current living situation? *

Renting, owning, shelter, etc.

Do you struggle with paying for housing or find yourself falling behind on payments? *

Yes No

In the past 12 months has the electric, gas, oil or water company threatened to shut off services in your home? *

Yes No

Do you have problems with any of these? *

Pests such as bugs, ants, or mice Mold Lead paint or pipes Lack of heat Oven or stove not working Smoke detectors missing or not working Water leaks Refrigerator issues None of the above

Are you on any housing waitlists (e.g., HUD, Section 8, local housing authority, or other voucher programs) or receive a rental subsidy? *

Yes No

Benefits & Support

Do you receive SNAP (Food Stamps)? *

Yes No

Do you receive WIC? *

Yes No

Do you receive TANF? *

Yes No

Are you enrolled in a Health Home? *

Yes No

If so, which health home?

Do you need assistance finding or keeping a job? *

Yes No

Do you want help with school or training (job training, GED, high school completion)? *

Yes No

In the past 12 months has lack of reliable transportation kept you from medical appointments, meetings, work, or getting things needed for daily living? *

Yes No

Health

Do you have any chronic illnesses or conditions (ex: diabetes, asthma)? *

Yes No

Please list/describe any chronic illnesses or conditions you have

Do you have any medications that require refrigeration? *

Yes No

Are you pregnant or postpartum? *

Yes No

If you're pregnant or postpartum, please enter due date or delivery date

Does the member have difficulty climbing stairs or bathing? *

Yes No

Do you require refrigeration for breastmilk? *

Yes No

Food & Nutrition

Are you currently receiving home-delivered meals or food services through a New York State (NYS) social services program? (e.g. Meals on Wheels, home-delivered meals for seniors, or other NYS food assistance programs) *

Yes No

Do you or anyone in your household have food allergies? *

Yes No

Please list any allergies or dietary restrictions (e.g. gluten free, halal, kosher, vegan)

Does the household need a refrigerator, microwave or cooking supplies? Please select what is needed

Refrigerator Microwave Cooking Supplies

Within the past 12 months, you worried that your food would run out before you got money to buy more? *

Yes No

Within the past 12 months, the food you bought just didn't last and you didn't have money to get more? *

Yes No

Meal Preference *

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

One application per family.

Food Box Application

Applicant Information

Housing & Living Situation

Benefits & Support

Health

Food & Nutrition

Household