Request Services

Please complete the form to be added to Food Equality Initiative’s waitlist.

Complete the form for each individual person seeking assistance. When moved from the waitlist, someone from Food Equality Initiative will contact you regarding next steps and additional required information.

If you need assistance filling out this form, please call (816) 800-0884.

Name(Required)

Name of person needing services

Is the person who needs services under the age of 18?(Required)

Yes

Address(Required)

Phone(Required)

Email(Required)

What is the medical diagnosis for needing our services?(Required)

What is the first and last name of the doctor who is currently treating you for this/these condition(s)?(Required)

What is your doctor's specialty or what type of doctor is he/she? Example: allergist, pediatrician, etc.(Required)

How many people are in your household?(Required)

What is your monthly household income?(Required)

Do you have any additional medical condition(s) we should be aware of?

Is there any other information you believe we should be aware of?

How did you hear about us?

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