Client Enrollment In order to be eligible for our services, you need to meet the following criteria.Please check which item pertains to you: Are you over 65+ and/or a person with a disability? Are you homebound or unable to shop for yourself? Do you live within the boundary area shown on the below map? First Name*Middle InitialLast Name*Phone*Email Date of Birth*PLEASE NOTE: Program eligibility is age-based 65+ and for people with disabilities. Date Format: YYYY dash MM dash DD Do you have a disability?*YesNoVeteran Status*VeteranNot a VeteranPrefer not to discloseGender*FemaleMaleOtherRace/Ethnicity*African AmericanAsian/Pacific IslanderHispanic/LatinoNative AmericanWhite/CaucasianMulti-RacialPrefer not to disclosePreferred LanguageHousehold Size*First indicate the number in your household. Then, select the income level describes you based on the size of your household.1 Person in Household2 People in Household3 People in HouseholdPrefer not to discloseIncome Level*You have selected 1 person in your household, now please select an income level that best matches your earningsLess than $11,770between $11,770 and $23,541more than $23,541Prefer not to discloseIncome Level*You have selected 2 people in your household, now please select an income level that best matches your earningsLess than $15,930between $15,930 and $31,861more than $31,861Prefer not to discloseIncome Level*You have selected 3 people in your household, now please select an income level that best matches your earningsLess than $20,090between $20,090 and $40,181more than $40,181Prefer not to disclosePlease list the other people or pets in your householdPlease use the + sign to create a new row for the next name, if that applies Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code CountyBuilding name:How did you learn about Store to Door?Emergency contact*Please use the + sign to add a new row for additional contacts, if that applies.First NameLast NamePhoneEmailRelationship Case ManagerFirst NameLast NameOrganization NamePhoneEmail Why do you need the service?*Do any of these programs or benefits apply to you? OPI (Oregon Project Independence) SNAP (Food Stamps or Oregon Trail Benefit) We’d like to get an idea of the length of time you expect to need our service. Are you looking for something short or long-term?*One time onlyOngoing: weeklyCall time for orders*Monday morning (9-12pm)Monday afternoon (12-5pm)Tuesday morning (9-12pm)Additional InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.