River Delivers Registration Step 1 of 12 8% Read before you start this formThis form will ask you to upload a picture of identification for each member of your household. The River also requires proof of household address (such as a bill or other piece of mail). It may take some time to fill out. Use the "Save and Continue Later" button at the bottom if you are interrupted. The River does not discriminate based on age, gender, employment status, or any of the other information entered on this page. The information on this form is not shared with any agency or persons outside of The River. If you have any questions, concerns, or issues with the form, please reach out to info@riverfoodpantry.org or call 608-442-8815 ext. 0. If you would rather update your information verbally, reach out via email or phone (above) to set up a time.Household Income Eligibility(Required)The River receives funding through The Emergency Food Assistance Program. Please read the below income eligibility requirement below for your household. By checking this box, I acknowledge having read the "TEFAP Household Income Eligibility" documentation and I acknowledge that my combined household income is at or below the income levels for eligibility.Name(Required) First Last Preferred NameOptional - complete this field only if your preferred name is different than your legal name.I am a(n): Existing River client, but new to delivery New River client Renewing delivery client Important Details, please read!Thank you for your interest in receiving groceries from our River Delivery program. Please answer the questions below and our staff will process your delivery request and send you a confirmation email or call with your chosen delivery day by end of day the following Monday. If you have any questions or concerns, please call us at 608-661-1222. Please note that at this time new delivery clients will be accommodated one week in advance. We are unable to supply same-day or week delivery for new clients. If you need food this week, please see the link below to arrange transportation to The River during our current curbside market hours of 10a-3p Tuesday-Friday. For your awareness, deliveries contain 40-50 lbs. of groceries, instead of the usual 85 lbs. loaded into cars during Curbside Grocery Distribution. Delivery sizes are reduced for several reasons, including to better fit into cars and to maintain food safety. For full perishable groceries from The River, please arrange transportation with the DOT link provided HERE to drive through our curbside grocery drop-off. Thank you for your understanding as we continue to improve this program and make deliveries as safe as possible.Verification of understanding(Required) I understand the information above. I know that someone will reach out to schedule my delivery by Monday and the delivery will arrive by end of next week.Head of HouseholdDate of Birth(Required) MM slash DD slash YYYY Are you 60 years of age or older?(Required) Yes No Delivery program available for those 60 years of age or older(Required)Food Bridge provides a free service to community members at or above the age of 60, living in Madison or Monona. Please call (608) 512-0000 to speak with a Delivery Case Manager before continuing forward in this form. Visit www.newbridgemadison.org/food-bridge for more details on Food Bridge's programming, or call 608-512-0000. I have read the above information and called a Delivery Case Manager to see if I qualify.Are you a veteran or active military member?(Required) Yes No Food Services available for veterans(Required)If you are experiencing food insecurity as a veteran, please call DryHootch at (608) 977-4214 to speak with a staff member and discuss the resources they have available. I have read through the above services provided for veterans and require a delivery from the River Food Pantry.Picture of ID(Required)Max. file size: 8 MB. Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mail with Name on ID for Proof of Address(Required)Max. file size: 8 MB. Email(Required) Primary Phone Number(Required)Alternate Phone NumberThis field is hidden when viewing the formPreferred method of communicationYour information will never be shared. The River will not contact you with any spam. Communication via email or phone will be for delivery or registration purposes only. Email Phone call How did you hear about River Delivers?This field is hidden when viewing the formAre you interested in our ePantry?The ePantry is the newest program of The River. Once a month you can place a fully customized order pantry order online to be delivered to you! You can find more information at the link below. If you click "Yes" you will receive an email with further details and instructions. https://riverfoodpantry.org/epantry Yes No FoodShare Status(Required)Please Select1 YES, we are currently on FoodShare.2 No, would like information.3 No, applied, not qualified.4 No, would like to apply.5 No, Not interested.Prefer not to sayHousing Status(Required)Please SelectRentOwnHotelShelterGroup HomeLiving with Family/FriendWithout HousingPrefer not to sayPrimary Language(Required)Please SelectEnglishHmongSpanishArabicMandarinOtherPrefer not to sayPrimary Language - Please Specify(Required)Primary Transportation(Required)Please SelectHousehold VehicleFamily/friend provides ridePublic Transit (Bus, Taxi, etc.)WalkBicycleMobility Device (Use of Wheelchair, Cane, Walker, etc.)Medical TransportationThis field is hidden when viewing the formPrimary Transportation - Please SpecifyGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayEthnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Lactose Intolerance Halal No Pork Kosher Peanut Allergy Shellfish Allergy Vegan Vegetarian Other None Prefer not to say Dietary Notes(other allergies, restrictions, etc.)Are there additional members in the household?(Required) Yes No How to order deliveries?Please check your email on additional information about your River Delivers application process. Thank you!Acknowledgment(Required) By checking this box, I acknowledge having read the "TEFAP Pledge" documentation below this text and accept the terms within the "TEFAP Pledge" document. Household Member #2Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a third member in the household?(Required) Yes No Household Member #3Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a fourth member in the household?(Required) Yes No Household Member #4Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a fifth member in the household?(Required) Yes No Household Member #5Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a sixth member in the household?(Required) Yes No Household Member #6Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a seventh member in the household?(Required) Yes No Household Member #7Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there an eighth member in the household?(Required) Yes No Household Member #8Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a ninth member in the household?(Required) Yes No Household Member #9Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a tenth member in the household?(Required) Yes No Household Member #10Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there an eleventh member in the household?(Required) Yes No Household Member #11Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Birth Date(Required) MM slash DD slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionIs there a twelfth member in the household?(Required) Yes No Household Member #12Name(Required) First Last Picture of ID(Required)Max. file size: 8 MB. Consent I agree to the privacy policy.Birth Date(Required) DD slash MM slash YYYY Relationship to Head of Household(Required)Please SelectSpouseChildRelativeFriendSignificant OtherRoommateGender(Required)Please SelectFemaleMaleNon-binaryPrefer not to sayVeteran or active military member?(Required) Yes No Ethnicity(Required)Please SelectAfrican AmericanAlaskan NativeAmerican IndianAsianHispanic or LatinxMiddle Eastern / North AfricanNative Hawaiian / Pacific IslanderWhiteMulti-racialPrefer not to sayEmployment Status(Required)Please SelectDisabilityEmployed - Part TimeEmployed - Full TimeNot EmployedSSI / RetiredStay at Home ParentStudentVeteran BenefitsWisconsin WorksLooking for Work - Full TimeLooking for Work - Part TimeOtherPrefer not to sayDietary Preferences(Required) Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or Restriction Δ
