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PA Membership SNAP Benefits Support Intake Form
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First Name
Last Name
Phone Number
Email
Preferred Contact Method
Call
Text
Email
Household Snapshot
How Many people live in your household?
1
2-3
4 or more
Age of household members (check all that apply)
Children (0-12)
Teens (13-18)
Adults (19-64)
Seniors (65+)
Do you currently receive or have you recently lost SNAP benefits?
Yes, currently receiving
Yes, recently lost
No, but experiencing food insecurity
Areas of Need
Check All That Apply
Groceries or food boxes
Gift Cards for essentials
Budgeting or meal planning support
Prayer and encouragement
All info will be kept private and used only by our pastoral care and support team to coordinate assistance.
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