Fuel the Community Registration Form

Fuel the Community Registration Form

Fuel the Community Registration Form
Urban League of Metropolitan Seattle and Rainier Valley Food Bank are now collaborating to offer health insurance enrollment assistance, health navigation and food distribution Thursdays from 2:30pm-5pm at ULMS Resource Center.

Below is a registration to help us understand better what our community needs every week!

For any transportation issues, time restrictions or other concerns please feel free to reach out to Pavi Montes: pmontes@urbanleague.org

We look forward to continuing to support you!

Please Fill Out the Registration Below:
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date

MonthDayYear
Date
Zip Code
Number of adults in the family
Number of children in the family
Address (Optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Within the past 12 months, did the food you purchase just not last and you didn't have money to get more?
Within the past 12 months, did you worry that your food would run out before you bought more?
Will you be picking up groceries at next week's food pantry?
Does your family have any dietary restrictions?
Should be Empty: