River Curbside Registration Read before you start this form!The River does not discriminate based on age, gender, employment status, or any of the other information entered on this page. The information on this form is not shared with any agency or persons outside of The River. If you have any questions, concerns, or issues with the form, please reach out to info@riverfoodpantry.org or call 608-442-8815. If you would rather update your information physically, you can do this when you come for curbside groceries or you can call or email us to set up a time.Household Information (Required)Head of Household Name(Required) First Last Number of Children (Age 0–17)(Required)Please enter a number from 0 to 15.Number of Adults (Age 18–59)(Required)Please enter a number from 0 to 15.Number of Seniors (Age 60+)(Required)Please enter a number from 0 to 15.Address(Required) 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 I am currently without housing Contact Information (Voluntary)We highly encourage you to share your contact information so that we can communicate important updates, such as food recalls, schedule changes, or closures due to weather. We send these types of emails and text messages very infrequently. We never spam, share, or sell your personal information.Email PhoneDemographics (Voluntary)We greatly appreciate any additional household information that you share with us. Demographic details allow The River to qualify for more grant funding so that we can purchase more food and supplies for you, our clients! Again, we will never share your personal information. We only report totals to funders, such as the total number of households with veterans that we serve. By telling us more about who you are, The River can do more to improve our programs so that we can better meet your needs! Primary Language English Hmong Spanish Arabic Mandarin Other Number of Veterans in HouseholdNumber of People with Disabilities in HouseholdNumber of People who are Asian/Asian American/Pacific Islander in HouseholdNumber of People who are Black/African American/African in HouseholdNumber of People who are Hispanic/Latinx in HouseholdNumber of People who are Middle Eastern in HouseholdNumber of People who are Native American/American Indian/Indigenous in HouseholdNumber of People who are White/Caucasian/European in HouseholdNumber of People who are Multi-Ethnic in Household2 or more races or ethnicitiesGender Female Male Non-binary Prefer not to say Dietary Preferences Diabetic Gluten Free Halal Kosher Lactose Intolerance No Pork Peanut Allergy Vegan Vegetarian Other None Prefer not to say Other Allergy or RestrictionAcknowledgement(Required)Scroll down for English, Spanish, and Hmong translations of the TEFAP Pledge document. By checking this box, I acknowledge having read the "TEFAP Pledge" documentation above this text and accept the terms within the "TEFAP Pledge" document.Acknowledgement(Required) By checking this box, I acknowledge having read the "TEFAP Household Income Eligibility" documentation and I acknowledge that my combined household income is at or below the income levels for eligibility.How did you hear about The River Food Pantry? Online/Google Social Media TV Radio Staff/Volunteer Word of Mouth Other Δ