Customer Registration Form

Customer Registration Form

Rhinelander Area Food Pantry
Due to COVID-19 restrictions, RAFP is currently using a temporary registration for all new customers. To use the RAFP, complete and submit the registration form below.

Please note:
- All RAFP customers must reside in Oneida County and be able to provide proof of residency
- All RAFP customers may use the Pantry every 14 days, unless it is an emergency
- All RAFP acknowledge they meet the income eligibity of less than 300% of the federal poverty line
- All RAFP customers may only claim the members that reside in the same household
Name *

First Name Last Name
What is your date of birth? *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email
example@example.com
I have read and confirm that my household meets the current income eligibility. This information can be found on the RAFP website under Recipient Info. *

Yes I am not sure. Please contact me with more information.
How many members are in your household? *
Please list the members in your household. *
Please list total monthly gross income. This includes all income such as wages, Social Security, SSDI, SSI, pension and child support.
Where does the monthly income come from?
Are you employed?

Yes No
How many other household members are employed?
Are you reporting zero income?

Yes No
Are you a Single head of Household with children under 18 years of age?

Yes No
Does your household currently receive FoodShare (food stamps)?

Yes No, we applied and do not qualify. No, but we would like to apply. No, we do not wish to apply. No, but we would like more information about FoodShare.
Proxy: Name of person(s) designated to pick up food on behalf of your household.
Please provide two references (name and phone number). References cannot reside in your household.
Do you have any special dietary considerations? We try to make these available when possible.

Food Allergies Low Salt Low Sugar/Sugar Free Gluten Free Dairy Free Vegetarian Fruits Fish
You will receive one RAFP ID card for your household. If you lose the ID Card, you are required to present picture identification at each visit.

RAFP customers may use the Pantry every 14 days.

Please read the Applicant Certification and Signatures statement below, then sign and you application. Please note that due to COVId-19 restrictions, we are not viewing proof documents. Your signature below attests that you are able to provide the necessary documents of proof upon request at any time.
Signature

Clear
Date

Month Day Year
Date
Please verify that you are human *
Should be Empty: