Food Request Form

Food Request Form
Thank you for choosing to order using our online services at Harrison County Community Services. Our goal with this program is to offer clients the opportunity to order online then have a day and time given to pick up your order at the office.

All food guidelines apply (once a month for food and we must verify your household).

Fields marked with an asterik are required. Please make sure you have completed all required fields.
Client Contact Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
To place an order, you must have a valid email address so that we can verify your order giving you a pick up date and time.
Date of Birth*

MonthDayYear
Please provide for our records
What is your Gender*

FemaleMale
What is your race?*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
Do you have a disability?*

NoYes
Do you or a family member have a food allergy that we may need to know about?*

YesNo
Client Allergy Details
Are you a Veteran?*

YesNo
Do you have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on your insurance coverage
What was the last grade you completed?*
Are you a full-time resident of Harrison County?*

YesNo
Do you need to add another member to your household?

YesNo
Additional Members of your Household
Household Member #2
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Date
What is their gender?

FemaleMale
What is their race?

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
What was the last grade they completed?
Do they have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on their insurance coverage
Are they a Veteran?

YesNo
Do they have a disability?

NoYes
Do you need to add another member to your household?

YesNo
Household Member #3
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Date
What is their gender?

FemaleMale
What is their race?

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
What was the last grade they completed?
Do they have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on their insurance coverage
Are they a Veteran?

YesNo
Do they have a disability?

NoYes
Do you need to add another member to your household?

YesNo
Household Member #4
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Date
What is their gender?

FemaleMale
What is their race?

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
What was the last grade they completed?
Do they have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on their insurance coverage
Are they a Veteran?

YesNo
Do they have a disability?

NoYes
Do you need to add another member to your household?

YesNo
Household Member #5
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Date
What is their gender?

FemaleMale
What is their race?

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
What was the last grade they completed?
Do they have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on their insurance coverage
Are they a Veteran?

YesNo
Do they have a disability?

NoYes
Do you need to add another member to your household?

YesNo
Household Member #6
Name

First NameLast Name
Relationship
Date of Birth

MonthDayYear
Date
What is their gender?

FemaleMale
What is their race?

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteOther
What was the last grade they completed?
Do they have health insurance coverage?*

Private InsuranceMedicareMedicaidVAOtherNone
Please provide more information on their insurance coverage
Are they a Veteran?

YesNo
Do they have a disability?

NoYes
Food Related Information
Would you like to receive USDA food commodities?*

YesNo
Select Food Items - Check all that you want - Orders filled based on availability*

DrinksCereal or other breakfast foodGreen beansCornPastaPasta sauceMac & CheeseCanned FruitPeanut ButterJellySoupsMisc. frozen itemsMisc. refrigerated itemsBread & pastriesSnacks & candyChickenBeefPork
Once your order is placed, it will be reviewed and you will receive an email with your pick-up time. If you don’t receive an email, check your spam folder. Be sure to add info@hccsi.net to your approved list.

Please click the submit button below when you are ready to place your request.
Should be Empty:

Food Request Form

Client Contact Information

Additional Members of your Household

Household Member #2

Household Member #3

Household Member #4

Household Member #5

Household Member #6

Food Related Information