Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Birthdate* Month Day Year Phone*Email* Email Newsletter I want to receive occasional updates on other helpful resources from Feeding Wimberley Total Number of People in Household by Age0-17*18-65*65+*Any Veterans?* Yes No Any People with disabilities?* Yes No Estimated Monthly Income*Currently Receiving Gov't Assistance (all that apply):* SNAP TANF Medicaid SSI NSLP (Free / Reduced Lunch Program) None Any food emergencies? (i.e. medical bills, loss of income, loss of home) Need to register a proxy?A proxy is a person designated by a client to act on their behalf (as necessary) throughout every process of The Emergency Food Assistance Program (TEFAP). Yes No Proxy InformationProxy Name First Last “I approve this person as my proxy.”* YesA proxy must be registered with HCFB prior to them picking up food on your behalf. A proxy must provide photo identification each time. HCFB must maintain each written proxy designation and their address on file. There may be a maximum of 2 proxies per client. A proxy may only represent 2 clients per distribution.