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2-1-1 Directory
Application for Assistance
Complete this form to sign up for our Emergency Mobile Food Pantry serving Riverside County!
If you need help filling out this form, please call (951) 703-3716, and leave a message.
Please allow up to 48 hours for a response to your request.
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Indicates required field
Name
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First
Last
Street Address
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City
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Zip Code
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Phone Number
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Email
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Date of birth (MM/DD/YY)
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What, if any, type of aid are you requesting from Legacy Shelters or one of their partners? (Select all that apply.)
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Employment
Food pantry
Community closet (i.e., household items, clothing &/or other necessities)
Medical
Housing
Rental assistance
Other
For community closet/other, please specify
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Do you need help obtaining an I.D., Driver's License or Social Security Card?
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Yes
No
Unsure
Including yourself, how many people slept in the same place with you last night?
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How many children under 18 are there in your household who are sleeping in the same location?
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What is the current problem you are experiencing? (You may list more than one.)
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For reporting purposes only, please specify your race:
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Asian or Asian American
Black or African American
Hispanic/Latino
Native American
Pacific Islander
White
Other
Unknown/decline to specify
You may upload applicable documentation here:
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Max file size: 20MB
Please accept
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I certify that the following information is true and authorize Legacy Shelters to verify any details I have voluntarily provided.
Typed Signature Required:
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Submit
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2-1-1 Directory