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Home Delivery Application

Delivery Location Options:

Grace Distribution Hub Delivery Radius: 410 (north), Harry Wurzbach (east), E. Hildebrand/Burr (south), and 281 (west)

KLCM Distribution Hub Delivery Radius: Wurzbach Pkwy (north), O'Connor/Crestway (east), Gibbs-Sprawl/Rittiman (south), and Thousand Oaks/410/35 (west)

Multi-line address
Birthday
Month
Day
Year
Race and/or Ethnicity (optional):

We collect this information to better understand who we serve and to support grant reporting. Your response will not affect your eligibility for services.

Do you experience food insecurity
Yes
No

Food insecurity is the lack of reliable access to sufficient, affordable, and nutritious food necessary for an active, healthy life.

Are you homebound due to a medical condition, disability, or other circumstances?
Yes
No
How often would you like home-delivered produce?
What delivery day do you prefer?
(optional)

Please upload a document from a healthcare provider or relevant authority confirming your homebound status. This may include a doctor’s note, medical record, or other verification.

(optional)

Please upload a document that demonstrates your financial situation, such as a recent pay stub, benefits letter, or other relevant paperwork. This information helps us confirm your eligibility for home delivery services.

(optional)
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