MFP New Client Intake

MFP New Client Intake
Thank you for your interest in becoming a Mitzvah Food Program client.
We are here to provide you and your family with fresh, frozen and nonperishable food with kosher options.

In order to begin the process of becoming a client, we ask that you fill out the following form. If you have any questions, contact or mitzvahfoodprogram@jewishphilly.org or 215.832.0509.

Please know that this form is not mandatory to receive food in person. This information is confidential and will not affect your eligibility for food. Every question must be answered clearly (N/A, none, or 0 if your answer does not apply). Our four pantries distribute nutritious food to all who are in need, regardless of race, income, gender, age, or religion. Additionally, this information is only required in order to become a full client of our pantry, not to receive emergency food.
Basic Information
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Postal Zip
Based upon your zip code we have chosen the appropriate pantry site location for you.

If you have any question or concern, please call 215-832-0509.
Mitzvah Food Pantry Location(single select).

Old York Road (Beth Sholom Congregation)Lower Bucks County (Congregation Tifereth Israel)Mainline (JFCS Brodsky Building)Northeast (KleinLife)Double check your zip code. A social worker will be in contact with you.
Mitzvah Food Pantry Location
Your Mitzvah Food Pantry Location is:
Personal Email
example@example.com
Mobile Phone
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Birthdate*

MonthDayYear
Date (Please use the calendar to enter birthdate)
Gender
Do you or any member of your Household identify as LGBTQIA+(Lesbian, Gay, Bisexual, Transgender, Queer or Questioning)?
Do you have mobility issues?
Do you need delivery service?

YesNo
Please note: Delivery service is not currently avilable at Old York Road and Lower Bucks at this time.
What is your household primary language?
Citizenship Status?
Are you a veteran?
Do you identify as LGBQT?
Do you have Jewish heritage?
Work Status
What is your household religion?
Religion Other*
What is your household race?
Race Other*

Members of Household Information
How many people are in your household including yourself?
Name2

First NameLast Name
Gender2
Work Status2
Citizenship Status2
Race2
Date of Birth2

MonthDayYear
Date
Name3

First NameLast Name
Gender3
Work Status3
Citizenship Status3
Race3
Date of Birth3

MonthDayYear
Date
Name4

First NameLast Name
Gender4
Work Status4
Citizenship Status4
Race4
Date of Birth4

MonthDayYear
Date
Name5

First NameLast Name
Gender5
Work Status5
Citizenship Status5
Race5
Date of Birth5

MonthDayYear
Date
Name6

First NameLast Name
Gender6
Work Status6
Citizenship Status6
Race6
Date of Birth6

MonthDayYear
Date
Name7

First NameLast Name
Gender7
Work Status7
Citizenship Status7
Race7
Date of Birth7

MonthDayYear
Date
Name8

First NameLast Name
Gender8
Work Status8
Citizenship Status8
Race8
Date of Birth8

MonthDayYear
Date
Name9

First NameLast Name
Gender9
Work Status9
Citizenship Status9
Race9
Date of Birth9

MonthDayYear
Date
Name10

First NameLast Name
Gender10
Work Status10
Citizenship Status10
Race10
Date of Birth10

MonthDayYear
Date
Name11

First NameLast Name
Gender11
Work Status11
Citizenship Status11
Race11
Date of Birth11

MonthDayYear
Date
Name12

First NameLast Name
Gender12
Work Status12
Citizenship Status12
Race12
Date of Birth12

MonthDayYear
Date
Name13

First NameLast Name
Gender13
Work Status13
Citizenship Status13
Race13
Date of Birth13

MonthDayYear
Date
Name14

First NameLast Name
Gender14
Work Status14
Citizenship Status14
Race14
Date of Birth14

MonthDayYear
Date
Name15

First NameLast Name
Gender15
Work Status15
Citizenship Status15
Race15
Date of Birth15

MonthDayYear
Date
Are you or is someone in your house a Holocaust Survivor?

YesNo
Total monthly income for your whole household.
What is your current housing situation?
Do you receive a HUD housing/section8/voucher
Dietary Information
Do you keep strict kosher?
Does someone in your household have special dietary needs?

Regular PackageCeliac (Gluten Free)Lactose IntolerantLower saltLower sugarNut Allergy
Does someone in your household have special dietary needs?
Other Dietary Restrictions
Additional Information
How did you hear about the Mitzvah Food Program?

Friend/Family MemberInternet SearchPhilabundance, Share Food Program,MAHN,BCOC or another organizationReligious Institution/LeaderOther
Recipient of Services Release and Waiver of Liability Agreement
I, (hereinafter the “Undersigned”) wish to receive services from a Volunteer and/or Agent through the Mitzvah Food Program (hereinafter referred to as “MFP”) service. The Undersigned understands that the Volunteer and/or Agent will perform certain activities related to serving as a volunteer and/or agent (“the Activities”).

Scope of Volunteer Position: The Undersigned understands that the scope of the Volunteer’s relationship with MFP is limited to a volunteer position; that the Volunteer is not an employee of MFP and no compensation is expected in return for services rendered; that MFP will not provide any benefits to the Undersigned beyond connecting the Undersigned and the Volunteer; and that the Undersigned is responsible for his/her/their own insurance coverage in the event of personal injury or illness arising out of the Activities.

Scope of MFP’s Role: The Undersigned expressly acknowledges that MFP is acting solely as an intermediary between beneficiaries in need of services and volunteers and/or agents willing to provide such services; that MFP’s involvement ceases once a volunteer and/or agent is connected with a beneficiary; and that MFP exercises no control over the receipt of services or any other agreement between the Undersigned and the Volunteer and/or Agent.

Release, Waiver and Indemnification: The Undersigned hereby releases, waives, discharges and covenants not to sue MFP and/or its insurers, its attorneys, its insurer’s attorneys, or anyone for whom MFP or its insurer may be legally liable (herein the “Releases”) for liability to the Undersigned, his/her/their personal representatives, employers, insurers, assigns, heirs, and next of kin due to any and all loss or damage, and any claim or demands therefore on account of injury to Undersigned’s person or property or resulting in death of Undersigned, whether caused by the negligence of the Releasees, or Volunteer, or Agent, or otherwise while Volunteer and/or Agent is on or around the Premises or in any way arising out of the Activities.

The Undersigned further hereby assumes full responsibility for and risk of bodily injury, death or property damage due to the negligence of Releases, or Volunteer, or Agent, or otherwise while on or around the Premises or in any way arising out of the Activities. The Undersigned further agrees to defend and indemnify and hold Releasees harmless from and against any and all loss, damages, injuries, liability, claims, suits, costs and expenses whatsoever, including reasonable attorneys' fees, regardless of the merit or outcome of any such claim or suit arising from or in any manner connected to the Activities.

The Undersigned further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of Pennsylvania and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

The Undersigned has read and voluntarily signs this release, indemnity and waiver of liability agreement and further agrees that no oral representations, statements, or inducements apart from the foregoing written agreement have been made.
I agree to the privacy policy.
Signature

Clear
Should be Empty:

MFP New Client Intake

Basic Information

Members of Household Information

Dietary Information

Additional Information

Recipient of Services Release and Waiver of Liability Agreement