VACF Food Distribution

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Food Distribution

Limited quantity. Appointments preferred. Please provide the information below.
Your Contact Information:*

PrefixFirst NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
E-mail
example@example.com
Cell Phone Number*
Home Phone Number
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Information About Your Household*
Child(ren) Information (For diapers)
Is this the first time you're registering to receive diapers?

YesNo
Eligible diaper-wearing children can receive diapers once a month, including those who receive diapers at the weekly food pantry. Limited supplies.
Please submit ONE of the required documents below for the children you are signing up for:

Birth certificate
Health insurance card
Any ID with the child's name and date of birth
Select the document(s) you would like to submit.

Cancelof
Select Your Appointment*
Would you like to get flu and/or COVID-19 vaccines?

FluCOVID-19
Would you like to get Flu/Covid vaccine?

YesNo
Do you have health insurance?

YesNo
ID Number on Insurance Card
Group Number on Insurance Card
RxBIN Number on Insurance Card
RxPCN Number on Insurance Card
Did any one help you to complete this form?

NoYes
If answered "Yes" in the question above, please name the person/organization that helped you:
When you arrive at the location to pick up food, please practice the following:
- Stay inside your vehicle
- Leave windows up at all time unless instructed differently
- Place valid photo ID on your dashboard for easy check-in
- Make sure your vehicle's trunk is empty
- Please arrive at your appointment time to avoid long wait or create traffic
- Please stay at home if you are feeling sick
Should be Empty: