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Please answer all questions thoroughly so that we may serve you better. Information may be shared with outside agencies or entities (including the San Antonio Food Bank for service purposes). Favor de responder a todas las preguntas de manera que podamos servirle mejor. Su información podrá ser compartida con otras agencias u entidades (incluyendo el Banco de Comida de San Antonio con propósitos de servirle).
Head of Household Name/ Nombre Completo:
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Last
language/ Idioma
Gender/Género
Female/Femenino
Masculine/ Masculino
Date of birth/Fecha de Nacimiento
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Address Line 2
City
State / Province / Region
ZIP / Postal Code
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American Samoa
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Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
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Bulgaria
Burkina Faso
Burundi
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Cameroon
Canada
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Chile
China
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Cocos Islands
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Congo
Congo, Democratic Republic of the
Cook Islands
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Cuba
Curaçao
Cyprus
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Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
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Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
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Palau
Palestine, State of
Panama
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Peru
Philippines
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Poland
Portugal
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Qatar
Romania
Russian Federation
Rwanda
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Saint Kitts and Nevis
Saint Lucia
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Samoa
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Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Other
No Fixed Address
Mailing Address/ Dirección de envio:
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Primary Phone/ Teléfono
*
Do you receive text messages on this phone? / ¿Recibe mensajes de texto en este número?
*
Yes/ Si
No
Secondary Phone/ Teléfono Secundario
Email/Correo Electrónico
How many people live in your household?/ ¿Cuantas personas viven en su hogar?
*
What method of communication do you prefer?
Email
Phone
Text
Are you?/¿Es usted?
*
American Indian or Alaska Native/Indio Americano o nativo de Alaska
Asian/Asiático
Black or African American/Negro o Africano Americano
Native Hawaiian or Other Pacific Islander/Nativo Hawaii o Isla del Pacific
White/Anglo/Blanco
Hispanic/Hispano
Are you?/ ¿Es usted?
*
Cuban/Cubano
Mexican/Mexicano
Puerto Rican/Puertorriqueño
South or Central American/de Sur o Centro América
Other Spanish culture or origin/ de otra cultura u origen Española
N/A
Household Composition/ ¿Es usted?
*
Single Parent/Padre/Madre Soltero(a)
Single Adult/Soltero(a)
Married/Casado(a)
Separated/Separado(a)
Divorced/Divorciado(a)
Seniors Raising Grandchildren/ Personas Mayores criando Nietos
Senior Living Alone/Persona Mayor viviendo Solo(a
Widowed/Viudo(a)
Two Parent Home/Hogar con dos padres
How many individuals in the household are/ ¿Cuántas personas en el hogar son o están?
Seniors (over 60/de edad mayor (más de 60)
Seniors (over 65)/ tiene 65 años o más
Physically Disabled/con discapacidad física
Victims of Abuse/ víctima(s) de abuso
Mentally Disabled/con discapacidad mental
Chronically Ill/con enfermedad crónica
Homeless/Sin Casa
Active Military/Activo militar
Retired Military/Retirado militar
Reserve Military/Reserva militar
Veteran/ Veterano
What is the Gross Income (before deductions) for all household members combined?/¿Cuál es el ingreso total (antes de deducciones) de todos los miembros de su hogar?
*
*
Weekly/Semanal
Every two weeks/Cada dos Semanas
Monthly/Mensual
Yearly/Anual
Have you received any services from HCFS in the past/ ¿Ha recibido servicios de Hill Country Family Services anteriormente?
*
Yes/ SI
No
Please check if you or any other household member receive assistance from any of the following sources/ Favor de anotar si usted o alguna persona en su hogar reciben uno de los siguientes servicios:
SSI/SSDI/Seguro Social
TANF (Temporary Assistance for Needy Families) / TANF (Asistencia Temporal Para Familias Necesitadas)
Free/Reduced School Lunch Program / Comidas Gratis o a Precio reducido escolares
SNAP (Food Stamps) / SNAP (Estampillas de Comida)
Medicaid/Medicare
WIC (Women, Infants and Children) / WIC (Mujeres, Infantes y Niños
Unemployment / Desempleo
Please complete the following information regarding ALL individuals (beside yourself) living in your home / Favor de llenar la información sobre todas las personas en su hogar aparte de usted:
Name/ Nombre Completo
Date of Birth/ Fecha de Nacimiento
Male/Female/Hombre/Mujer
Relationship/Relación a usted (hijo(a), esposo(a), etc.,)
Indicate the name(s) and phone number(s) of authorized individual(s) (proxy) whom you would like to allow to be able to pick up product for your household/Favor de apuntar el nombre y el número de teléfono de la persona(s) que le gustaría permitir recoger su despensa:
*
Hill Country Family Services (HCFS) assists individuals and families in Kendall County who are experiencing a crisis. Definition of Crisis: A recent stressful EVENT or TRAUMATIC CHANGE in a person's life resulting in an unstable situation in the household and/or finances within the last 90 days. We assess all clients to determine if they are experiencing a crisis. We require at least 3 business days to process this assessment and to determine the best course of action for each client. Focusing on individuals and families in crisis allows us to make a measurable and sustainable difference in the lives of those we serve.
Hill Country Family Services (HCFS) ayuda a las personas y familias en el Condado de Kendall que están experimentando una crisis. Definición de Crisis: Un EVENTO estresante reciente o CAMBIO TRAUMÁTICO en la vida de una persona que resulta en una situación inestable en el hogar y / o las finanzas dentro de los últimos 90 días. Evaluamos a todos los clientes para determinar si están experimentando una crisis. Requerimos al menos 3 días hábiles para procesar esta evaluación y determinar el mejor curso de acción para cada cliente. Centrarnos en las personas y familias en crisis nos permite hacer una diferencia medible y sostenible en las vidas de aquellos a quienes servimos.
What kind of services do you need? / ¿Qué tipo de servicios necesitas?
*
What county do you live in? / ¿En sue país vives?
Date of crisis / Frecha de su crisis
*
Can you wait up to three business days to be helped? / ¿Puedes esperar hasta tres días hábiles para que te den ayuda?
*
Yes / Sí
No
What EVENT caused your crisis and when did this happen? / ¿Qué evento causó su crisis y cuándo sucedió esto?
*
By signing below, I certify that: I am a member of the household living at the address provided above and that, on behalf of the household, I apply for USDA Foods that are distributed through The Emergency Food Assistance Program; all information provided to the agency determining my household’s eligibility is, to the best of my knowledge and belief, true and correct; and if applicable, the information provided by the household’s “Authorized Representative” (as named above) is also, to the best of my knowledge and belief, true and correct. Al firmar a continuación, certifico que: Soy un miembro del hogar que vive en la dirección indicada anteriormente y que, en nombre del hogar, solicito alimentos del USDA que se distribuyen a través del Programa de Asistencia de Alimentos de Emergencia; toda la información proporcionada a la agencia que determina la elegibilidad de mi hogar es, a mi leal saber y entender, verdadera y correcta; y si corresponde, la información proporcionada por el “Representante Autorizado” del hogar (como se menciona a continuación) también es, a mi leal saber y entender, verdadera y correcta.
Signature/Firma de Cliente
*
Phone
This field is for validation purposes and should be left unchanged.
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Street Address
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Poland
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Qatar
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Samoa
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Email
*
Are you part of a group or organization that is volunteering with HCFS?
Yes
No
If Yes, what is the name of the group?
Which days are you available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is this for Court Directed Community Service?
Yes
No
Submit
Reset
×
Random Hangers Volunteer Form
First and Last Name
*
Address
Street Address
Street Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Brazzaville)
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
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Mexico
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Monaco
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Netherlands
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Niger
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North Macedonia
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Oman
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Panama
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Philippines
Poland
Portugal
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Qatar
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Country
Phone
Email
*
Are you part of a group or organization that is volunteering with HCFS?
Yes
No
If Yes, what is the name of the group?
Which days are you available to work?
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Is this for Court Directed Community Service?
Yes
No
Submit
Reset
×
Volunteer Events Volunteer Form
First and Last Name
*
Address
Street Address
Street Address Line 2
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Congo (Brazzaville)
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
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Dominican Republic
East Timor (Timor Timur)
Ecuador
Egypt
El Salvador
Equatorial Guinea
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Estonia
Eswatini
Ethiopia
Fiji
Finland
France
Gabon
Gambia, The
Georgia
Germany
Ghana
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Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
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Hungary
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India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
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Japan
Jordan
Kazakhstan
Kenya
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Korea, North
Korea, South
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
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Liberia
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Lithuania
Luxembourg
Madagascar
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Mali
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Panama
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Paraguay
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Philippines
Poland
Portugal
Puerto Rico
Qatar
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Rwanda
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Saint Lucia
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Samoa
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Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
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Slovakia
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Solomon Islands
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Spain
Sri Lanka
Sudan
Suriname
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Switzerland
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Tonga
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Vatican City
Venezuela
Vietnam
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Yemen
Zambia
Zimbabwe
Country
Phone
Email
*
Are you part of a group or organization that is volunteering with HCFS?
Yes
No
If Yes, what is the name of the group?
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