Client Enrollment In order to be eligible for our services, you need to meet the following criteria: Please check which item pertains to you Are you over 65+ and/or a person with a disability? Are you homebound or unable to shop for yourself? Do you live within the boundary area shown on the below map? First Name*Middle InitialLast Name*Phone*Email Date of Birth*PLEASE NOTE: Program eligibility is age-based 65+ and for people with disabilities. Do you have a disability?*YesNoGender*FemaleMaleEthnicity*African-AmericanAsian/Pacific IslanderHispanic/LatinoNative AmericanWhite/CaucasianMulti-RacialPrefer not to discloseHousehold Size*First indicate the number in your household. Then, select the income level describes you based on the size of your household.1 Person in Household2 People in Household3 People in HouseholdIncome Level*You have selected 1 person in your household, now please select an income level that best matches your earningsLess than $11,770between $11,770 and $23,541more than $23,541Income Level*You have selected 2 people in your household, now please select an income level that best matches your earningsLess than $15,930between $15,930 and $31,861more than $31,861Income Level*You have selected 3 people in your household, now please select an income level that best matches your earningsLess than $20,090between $20,090 and $40,181more than $40,181Please list the others in your householdPlease use the + sign to create a new row for the next name, if that applies Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Building name:How did you learn about Store to Door?Emergency contact*Please use the + sign to add a new row for additional contacts, if that applies.NamePhoneEmailRelationship Payment Method*CheckDebit/visa CardSNAPConservator (Bill payer / Financial manager)NameAddressPhone Case Manager nameCase Manager contact infoPhoneExtensionBranch numberemail Why do you need the service?*Do any of these programs or benefits apply to you? OPI (Oregon Project Independence) Oregon Trail Card (SNAP - Foodstamps) We’d like to get an idea of the length of time you expect to need our service. Are you looking for something short or long-term?*One time onlyOngoing: weeklyCall time for orders*Monday morning (9-12)Tuesday morning (9-12)Tuesday Afternoon (1-3)Delivery InstructionsAdditional InformationPhoneThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle AJAX powered Gravity Forms.