6436 US Hwy 85, Suite U • Fountain • CO • 80817
(behind Wendy's & Hangry Ohana- click for map)
719-387-9919
Food Pantry • Pregnancy Center • Life Skills • Counseling
FeedFountain.org
Primary Client 1
Client Registration Form
Entries with a red * are required. Leaving this form before pressing the Submit button will loose all your work.
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Other
Household
Members
2
First Name *
Last Name *
Date of Birth *
Last 4 of Social Sec # *
Gender *
3
4
5
6
7
Address *
Zip *
Ethnicity *
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Church (optional)
How did you find us?
Describe how this stressful situation happened.
Phone *
Monthly Income
Monthly Expenses
Housing
Utilities
Auto Payments
Auto Insurance+Gas
Medical+Dental+Insurance
Phones
Food
Personal Care
Cable+Internet
Other Expenses
Housing
Employment
TANF+AFDC
Food Stamps
SSI+SSDI+VA
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Medicaid
Other Income
C4L Terms of Service
I understand that Connections4LifeCenter, hereafter C4L, expressly disclaims any implied warrants of merchantability or fitness of food for a particular use. These are no expressed warranties in relation to this gift of food. All food is donated to C4L and we cannot be held liable for donated food items.
"If in doubt, throw it out."
I further agree to hold C4L and it's volunteers harmless from any claims, losses and causes of action, law suits or obligations in regards to donated goods or food product received.
8
Spouse
or Significnt other
Email *
Confirm Email *
