Date of Birth
How many children under 18 live in your home?
How many adults live in your home?
Is your household able to pay for the cost of weekly food
and essential supplies at this time?
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Yes
No
"We worried whether our food would run out before we got money to
buy more.” Was that often true, sometimes true, or never true for your household in the last 6
months?
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Often true
Sometimes True
Never True
"The food we bought just didn’t last, and we didn’t have money to
get more.” Was that often true, sometimes true, or never true for your household in the last 6
months?
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Often true
Sometimes True
Never True
Has your anyone in your household lost employment as a result of
COVID?
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Yes
No
Do you have health insurance for yourself and your
family?
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Yes
No
Has your diet changed over the past six months? Y or N
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Yes
No
If yes, how has your diet changed?
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More fresh fruits and vegetables
Less fresh fruits and vegetables
More unhealthy/highly processed foods
Less unhealthy/highly processed foods
No Change
Do you think COVID will impact your household’s ability to
access food in the next year?
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No impact at all
Not sure
Slight impact
Major impact
Have you or anyone in your household participated in
Children’s Aid Go!Healthy programming, such as Food Box, Go!Chefs or SNAP-Ed parent or child nutrition
workshops?
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Yes
No
Are you interested in learning more about Go! Healthy
programs and resources?
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Yes
No
Did you know Children’s Aid runs health centers serving children and adolescents in
Harlem and the South Bronx? Click here for more information.
Electronic signature. I verify that the statements on this
application are true & accurate. (Type full name)
