Client Enrollment Due to increased demand in response to the COVID-19 crisis, Store to Door is currently unable to immediately enroll new clients at this time. Individuals in need of services are still encouraged to complete the online enrollment form below to be placed on a waitlist. All prospective clients will be contacted to confirm your placement on the waitlist. Thank you for your patience. 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 Initial Last Name* Phone*Email Date of Birth*PLEASE NOTE: Program eligibility is age-based 65+ and for people with disabilities. YYYY dash MM dash DD Preferred PronounsExample: he/him, she/her, they/them Do you have a disability?* Yes No Veteran Status* Veteran Not a Veteran Prefer not to disclose Gender* Female Male Other Race/Ethnicity* African American Asian/Pacific Islander Hispanic/Latino Native American White/Caucasian Multi-Racial Prefer not to disclose Preferred Language Household 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 Household 2 People in Household 3 People in Household Prefer not to disclose Income Level*You have selected 1 person in your household, now please select an income level that best matches your earnings Less than $12,880 between $12,880 and $25,760 more than $25,760 Prefer not to disclose Income Level*You have selected 2 people in your household, now please select an income level that best matches your earnings Less than $17,420 between $17,420 and $34,840 more than $34,840 Prefer not to disclose Income Level*You have selected 3 people in your household, now please select an income level that best matches your earnings Less than $21,960 between $21,960 and $43,920 more than $43,920 Prefer not to disclose Please list the other people in your householdPlease use the + sign to create a new row for the next name, if that applies Do you have pets in your home?Please use the + sign to create a new row for the next name, if that appliesNameType of Animal Address* 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 County Building 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 only Ongoing: weekly Call time for orders* Monday morning (9am-12pm) Monday afternoon (1-3pm) Tuesday morning (9am-12pm) Tuesday afternoon (1-3pm) Additional InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneThis field is for validation purposes and should be left unchanged.
