Upbuild Foundation Family Intake Form – Food Assistance Program For questions, contact: info@upbuildfoundation.com Fill out this form and click "Submit Intake Form". Your email app will open with your answers. Please click "Send" in your email to finish submitting your request. Household Information Head of Household Name Phone Number Email Address Preferred Contact Method Phone Text Email Primary Language Address City ZIP Code Household Composition List household members (including head of household) Name Age Relationship Dietary Restrictions Total household members Children under 18 Seniors (65+) Food Needs & Restrictions Food allergies or restrictions? Yes No If yes, specify: Food preferences (optional): Fresh produce Halal Vegetarian Vegan Gluten-free Low-sodium Shelf-stable items Other: Assistance Needed Support requested: Monthly food box Emergency food box Groceries Hot meals Hygiene items Other: Urgency level: Immediate (24–48 hrs) Within a week Ongoing support Transportation & Delivery Able to pick up food box? Yes No – need delivery If delivery needed – best times: Special instructions: Consent & Verification I confirm the information provided is accurate and consent to be contacted for assistance. Signature (type your full name) Date Submit Intake Form After you click submit, your email program will open with this form's answers. Please send the email to complete your submission.
