Sustained Nutrition Referral Checklist HTML Cook For Vets is currently only serving residents of Virginia and Washington, D.C. VID # First Name Last Name Email Address Address Line 2 City US States - Select State - Virginia Washington DC Zip Housing Status Stable Unstable If unstable housing, please provide details (i.e. immediate and long-term housing plans): Phone Alternate Phone Preferred method of communication Phone Call Text Message Veteran Verification DD-214 Vet. ID Card Other HTML Household Information: Number of people in household Ages Number of children in household Children's Ages Number of pets in houshold Dog Food: None Dried Wet Cat Food: None Dried Wet Will someone be able to answer the door upon delivery? Yes No HTML If no, list point of contact Contact Name Contact Relationship Is there a code, buzzer or lockbox needed to drop off the delivery? Yes No If yes, provide info for drop-off: Other required delivery instructions HTML Reason for requesting service: Physical Mobility Issues Illness Injury Hospitalization Elderly Mental PTSD Depression Anxiety Social Isolation Substance Abuse Financial Low income Unemployment Homelessness Please Explain: Other (Please Explain): HTML Other information Services Prefered Prepared Meals Non-perishable Groceries Perishable Groceries Access to cold storage (ie. refrigeration): Yes No Access to re-heating (ie. stove/microwave): Copy Yes No Food Allergies/Dietary Requirements Yes No If yes, please describe dietary requirements: Additional information you would like to provide: HTML Deliveries take place on Saturdays between 1:00 & 5:00 PM.The referring agency will let you know the date of the monthly deliveries.Cook For Vets' volunteers do not make contact before deliveries.If no response upon delivery drop-off, bags will be left at the household entrance.All inquires are to be handled through the referring agency.Cook For Vets can deny or cancel referrals and deliveries at its sole discretion. If you are a human seeing this field, please leave it empty.
