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 Initial
Last Name*
Phone*
Email
Date of Birth*
PLEASE NOTE: Program eligibility is age-based 65+ and for people with disabilities.
Do you have a disability?*
- Yes
- No
Gender*
- Female
- Male
- Other
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 $11,770
- between $11,770 and $23,541
- more than $23,541
- 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 $15,930
- between $15,930 and $31,861
- more than $31,861
- 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 $20,090
- between $20,090 and $40,181
- more than $40,181
- Prefer not to disclose
Please list the other people or pets in your household
Please use the + sign to create a new row for the next name, if that applies
Address*
Street Address Address Line 2 City 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 Name Last Name Phone Email Relationship
Payment Method*
- Check
- Debit/Visa Card
- SNAP (Food Stamps or Oregon Trail Benefit)
Case Manager
First Name Last Name Organization Name Phone Email
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 (9-12)
- Tuesday morning (9-12)
- Tuesday Afternoon (1-3)
Additional Information
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email
This field is for validation purposes and should be left unchanged.