Client Enrollment

Due to increased demand, 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.

Preferred Pronouns

Example: 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 household

Please 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 applies

Name	Type of Animal

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

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 (9am-12pm)
Monday afternoon (1-3pm)
Tuesday morning (9am-12pm)
Tuesday afternoon (1-3pm)

Additional Information

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

This field is for validation purposes and should be left unchanged.