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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussiaRwandaRéunionSaint 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 IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country EmailThis field is for validation purposes and should be left unchanged.
