SSFM Monthly Break-down
Organization Name:
First Name
Last Name
Email
Phone Number
Address
Apartment, suite, etc.
City
State
Postal / Zip Code
Counties you serve, please check all that apply:
Collin
Dallas
Denton
Ellis
Hunt
Johnson
Kaufman
Navarro
Parker
Rockwall
Tarrant
Van Zandt
Wise
Other
Please provide the following information:
First Contact Details
First Contact Ethnicity
Choose One
African American
Asian
Caucasian
Hispanic
How many men did you serve in your first contact ethnicity? (Please breakout veteran, disabled or elderly).
How many women did you serve in your first contact ethnicity? (Please breakout veteran, disabled or elderly).
How many children in your first contact ethnicity (under 18) did you serve:
First Contact Additional Comments:
Second Contact Details
Second Contact Ethnicity
Choose One
African American
Asian
Caucasian
Hispanic
How many men did you serve in your second contact ethnicity: (Please breakout veteran, disabled or elderly).
How many women did you serve in your second contact ethnicity: (Please breakout veteran, disabled or elderly).
How many children in your second contact ethnicity (under 18) did you serve:
Second Contact Additional Comments:
Third Contact Details
Third Contact Ethnicity
Choose One
African American
Asian
Caucasian
Hispanic
How many men did you serve in your third contact ethnicity? (Please breakout veteran, disabled or elderly).
How many women did you serve in your third contact ethnicity? (Please breakout veteran, disabled or elderly).
How many children in your third contact ethnicity (under 18) did you serve?
Third Contact Additional Comments:
Fourth Contact Details
Fourth Contact Ethnicity
Choose One
African American
Asian
Caucasian
Hispanic
How many men did you serve did you serve in your fourth contact ethnicity? (Please breakout veteran, disabled or elderly).
How many women did you serve in your fourth contact ethnicity? (Please breakout veteran, disabled or elderly)
How many children in your fourth contact ethnicity (under 18) did you serve?
Fourth Contact Additional Commenst:
If you provide prepared group meals:
How many meals are served per month? (Please break-out ethnicity, elderly, veteran, disabled, children under 18)
Comment
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