*Who is completing this form? ---RecipientSpouseAnother family memberOther (please explain below)

*Explain here:

*First Name:

*Last Name:

*Your Email:

*Your Phone Number:

We provide delivery services to individuals in Livermore, Pleasanton, Dublin, San Ramon and Danville. For those living outside those cities, meals may be picked up at our kitchen in Pleasanton.
*Please provide your city of residence:

*Your Street Address:

*Zip code:

How did you hear about Culinary Angels?
Family or FriendCancer Support Community (CSC)Kaiser PermanenteStanford Valley HealthCareReligious OrganizationFertile GroundworksSunflower HillCulinary Angels WebsiteSocial Media (Facebook, Instagram)NewspaperOther

*Please include a description of your health challenge:

*I have read the following General Allergen Disclaimer:

Culinary Angels does not guarantee an allergen-free environment. Our meals may contain or come into contact with dairy, gluten, soy, tree nuts, peanuts, nut butter/oils, corn, eggs, wheat, sesame, & other food allergens. It is the responsibility of the recipient to alert Culinary Angels to any and all food allergies/intolerances.

Your acceptance above releases Culinary Angels of any liability. Thank you.

*Do you, your caregiver or a household member have known food allergies? YesNo

You are enrolling in the Culinary Angels Meal Delivery Program and will be receiving meals. You have stated you have a food allergy or intolerance to the items listed below. Culinary Angel meals may contain one or more of these foods, which you are aware of and would still like to continue receiving our meals. Meals containing these allergens will be labeled as such, however, we do not guarantee an allergen-free environment. It is the responsibility of the recipient to avoid consuming these meals, releasing Culinary Angels of any and all liability. Thank you.
*The recipient must fill at least 1 line of the food allergy table below. List food names and note if it is a food allergy or intolerance:
1 AllergyIntolerance
Additional food allergy? YesNo

2 AllergyIntolerance

Additional food allergy? YesNo

3 AllergyIntolerance

Additional food allergy? YesNo

4 AllergyIntolerance

Additional food allergy? YesNo

5 AllergyIntolerance

Responding to the following questions will not impact your ability to receive meals from Culinary Angels. They are meant to help us better understand and provide services to our recipients. In addition, as a nonprofit we are often required to report certain demographic information to qualify for grants and funding. All information you share is confidential and will be kept private.

Date of Birth:

*Gender: ---MaleFemaleNon-binaryDecline to answer

*How would you describe your race or ethnicity? ---Hispanic, Latino or SpanishWhiteBlack or African AmericanAmerican Indian or Alaskan NativeAsian (includes Far East, Southeast Asia, and the Indian subcontinent)Native Hawaiian or other Pacific IslanderDecline to answer

*What is your primary language?

*What is your total annual household income? ---$0-$35,000$35,001-$58,000$58,001-$85,000$85,001-$115,000$115,001+Decline to answer

*Please indicate which of these designations apply to you (check all that apply):
Senior Citizen (age 62+)Youth (under 25)Person with disabilitiesResident of female headed householdUnhousedNone of the aboveDecline to answer

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