Data Sheet Form Name GenderMaleFemale Address Town State Zip County Township/Borough Home Phone Cell phone Taxting CapacityYesNo Email Address Date of Birth Social Security(Last 4 digits) VeretanYesNo Marital StatusDivorcedMarriedSeparatedSingleWidowed Living SituationAloneSpouseWith other family member Emergency Contact Name Address Phone Relationship Income Unmarried with annual income of $14,580 or lessYesNo Husband and wife combined annual income of $19,720 or lessYesNo Complete "Both" Ethnicity and Ethnic Race EthnicityHispanic/LatinoNot Hispanic/Latino Ethnic RaceAmerican Indian/AlaskanAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderNon-Minority (White or non-Hispanic)White HispanicOther Nutritional Risk Score 6 or HigherYesNo