Food for Change Food Scholarship Application

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The Food Scholarship is a way to provide groceries at no cost to participants, to stretch your grocery budget, and support your journey to a healthy lifestyle. Food scholarship participants earn food scholarships by agreeing to completing their current enrolled program.

Participation in this program is voluntary and will not affect your standing in the sponsoring program. Thank you for taking the time to complete this application. If you have any questions or concerns, please contact your program liaison.

If you have filled this form out previously, DO NOT FILL IT OUT AGAIN. Please contact your program liaison to ensure you are active in the system. Filling out the form multiple times can lead to errors and a delay in your enrollment into the program. Thank you for your cooperation.

Food Scholarship Program

First Name

Last Name

Date of Birth (Month/Day/Year)

Please enter format MM/DD/YYYY

Gender Identity

FemaleMalePrefer Not to Answer

Gender

FemaleMaleTransgenderNone of ThesePrefer Not to Answer

Street Address

City

County

Zip Code

Phone Number

E- mail Address

Marital Status

SingleMarriedCommon-LawSeparatedDivorcedWidowedSelect one.

Housing Type

Public (Social) HousingEvacueeOwn HomePrivate RentalUnhousedEmergency Shelter / Mission / TransitionalWith Family / FriendsYouth Home / ShelterVehicleUniversity Owned Student HousingSelect one.

Contact Preference (please check one):

Voice*Text*E-mailChoose as many as apply.

*Standard data fees & text messaging rates may apply based on your plan with your mobile carrier.

Language Spoken in the Household

EnglishSpanishVietnameseMandarin ChineseOther Choose as many as apply.

Ethnicity

American Indian / Alaskan NativeAsianBlack / African AmericanHispanic / LatinoNative Hawaiian / Other Pacific IslanderWhitePrefer Not to AnswerChoose as many as apply.

Self-Identifies As:

DisabilityMental IllnessPregnantVeteranPostpartumBreastfeedingEvacueeFood for Change - Food Scholarship Choose as many as apply.

Highest Level of Education Completed

Grades 0-8Grades 9-11High School DiplomaGEDPost Secondary (some)Tradeschool / Professional Accreditation2 Year Degree4 Year DegreeMaster's DegreePhDHighest degree or level of schooling. If you are currently enrolled in college but have not yet earned a degree or accreditation, select "Post Secondary (some)."

Employment Type

Homemaker/Stay at home parentOut of work for more than 1 yearOut of work less than 1 yearPost Secondary StudentFull-TimePart-TimeNoneOtherRetiredSelect one.

Income Type

Select one primary income source.

Monthly Income (NOT annual)

Do not enter annual or yearly income. Only income in the past MONTH.

Dietary Considerations

Dairy AllergyHigh Blood PressurePeanut AllergyVeganVegetarianDiabeticHigh CholesterolPork AllergyEgg AllergyKosherSeafood AllergyGluten AllergyHalalSulfite Allergy ThyroidChoose all that apply. Please indicate any food allergies or dietary restrictions so we can better serve you.

Would you like to be contacted to receive help with a SNAP or Medicaid application?

YesNo

Please provide your preferred call-back time (Check all that apply)

Monday-Friday: 8:30 a.m. - 12:00 p.m.Monday-Friday: 1:00 p.m. - 5:00 p.m.Saturday - 9:00 a.m. - 1:00 p.m.

Substitute Shopper Designation:

If you are unable to shop, you can select up to two Substitute Shoppers to shop for you. A "Sub" Shopper is a person you give permission to use your Food Scholarship. This could be a spouse a family member or a close friend. By sharing the Food Scholarship, you as the participant are responsible for the actions & statements of the Sub Shopper. Please review the Food Scholarship Rights & Responsibilities (English version, Spanish version).

By initialing, you are acknowledging and agreeing to the Sub Shopper Policy:

Your Initials

Sub-Shopper #1

First and Last Name of Sub-Shopper #1 (do not type your own name)

Sub-Shopper #2

First and Last Name of Sub-Shopper #2 (do not type your own name)

Food Scholarship Application Agreement:

By signing below I, acknowledge and confirm that the information in the Food Scholarship Application is complete & correct. I understand that purposely giving false or misleading information may result in disqualification of the Food Scholarship. By signing below I am agreeing to the terms and conditions laid out in the Participant's Rights & Eligibility Section. By signing below, I am also providing Houston Food Bank permission to contact me electronically, including surveys concerning program participation and quality and updates regarding program participation and operations.

Disclaimer

The Houston Food Bank respects your information and wants to ensure it remains private. Providing information electronically can be safer than providing information on paper. Only certain staff and volunteers can log in to the system, and each person has been trained and has signed an agreement to keep your information private. We may use your personal information for a variety of reasons:

To Improve Our Programs: We may use your information to improve our programs or activities. For examples, staff may look at information to review the quality of services that people receive
To Do Research: We may use your information for research and analysis. Any reports produced with the data will not identify your individual information. Our staff and volunteers will only share your information with qualified persons outside of our agency.
To Connect You with Other Programs: At your request, we may share your personal information to see if you are eligible for other benefits or programs such as Social Security benefits for SNAP
To Report Abuse, Harm or Neglect: We are required by law to report any cases of suspected abuse or neglect of children or vulnerable adults. We are also required to share information about you to law enforcement in certain cases, for example, if you cause harm to a member of our staff, another client, or if you damage our property. We may also share your personal information in case of a threat to the public, such as terrorist attack or natural disaster.
To the extent HFB has access to Student “education records” that are subject to FERPA, HFB is deemed a “school official”, as each of these terms are defined under FERPA. HFB agrees that it shall not use education records for any purpose other than in the performance of the Agreement. Except as required by law, HFB shall not disclose or share education records with any third party unless permitted by the terms of the Agreement or as may be required by law or court of competent jurisdiction

Please allow 1 week for your application to be entered into the system.

Food Scholarship Recipient Signature:

If Scholarship recipient is a minor, their parent/guardian needs to complete below:

I (Parent/Guardian) grant permission for my child to participate in the Food Scholarship Program. I certify that I have read and understood all information on applicable forms, and allow my child to participate unless I provide verbal and/or written consent to the program staff to discontinue. I understand my rights and responsibilities as stated above.

Parent/Guardian Signature:

After choosing "Submit," you will be will redirected to an acknowledgement page with your new Food For Change ID.