Today's Date * MM DD YYYY Organization Name * Organization Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Would your organization's food distribution/pantry be at the location listed above? * Yes No Does your organization own/lease the location listed above? * Yes No If you are affiliated with a school (Elementary, Secondary, or College) please list below: If you are affiliated with a senior citizens program please list below: Organization's Point of Contact: Name * First Name Last Name Organization's Point of Contact: Title * Organization's Point of Contact: Phone # * (###) ### #### Organization's Point of Contact: Email * Organization's Secondary Contact: Name * First Name Last Name Organization's Secondary Contact: Title * Organization's Secondary Contact: Phone # * (###) ### #### Organization's Secondary Contact: Email * What county does your organization serve? * Note: these are the only counties in our service area. You may select more than one. Collin Dallas Delta Denton Ellis Fannin Grayson Hopkins Hunt Kaufman Lamar Navarro Rockwall What is your organization’s mission? Does your organization have a 501(c)(3) or church designation? * Yes No Please provide your organization's EIN: * How is your organization funded? * Does your organization operate with mostly paid staff or volunteers? * Paid Staff Volunteers Mixture of Paid Staff/Volunteers Do you partner with any other organizations on a regular basis as part of your outreach?* * Yes No If you answered "yes" to the above, please list which organizations: Describe your general program(s) * Please select the categories that currently describe your program (Select all that apply): * Food Pantry (providing groceries) Soup Kitchen/Meal Site Emergency Shelter (90 days or less) Day Care Senior Program Group Home Rehab/Transitional Housing After School Program None of the Above Does your organization provide any of the following services? * Medical/Mental Health Transportation Job Training Rent/Utility Assistance ESL Classes Mentoring Clothing Counseling/Coaching Other How does your organization reach neighbors? (Ex: social media, flyers, etc.) Please provide username and/or links to your social channels. * Have you or your organization previously submitted an application to become a food pantry or distribution partner of any of the following entities?* * North Texas Food Bank Sharing Life Crossroads Community Services None of the Above Please list all zip codes that your program serves: * How long has your organization been providing food assistance? * Please provide current days and hours of operation for your food assistance program: * How often do you allow a client/family to receive food? * Daily Weekly Bi-Weekly Monthly Quarterly Twice per year Annually Emergency Only How is your food program funded? * How many neighbors are you currently serving on a regular basis? * Does your organization serve any of these vulnerable populations? (Select all that apply): * Children (0-18) Seniors (60+) People experiencing homelessness People with disabilities People affected by substance abuse Victims/survivors of domestic violence Military/Veteran LGBTQIA+ Black/Indigenous/People of Color Other Do you deliver food to clients? * Yes No Homebound only In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, Crossroads Community Services Inc. is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), age, disability, and reprisal or retaliation for prior civil rights activity. Would you be able to adhere to the USDA's civil rights regulations and policies? * Yes No Do neighbors have to pay / give donations to receive food? * Yes No Do neighbors have to fill out an application for food? * Yes No Does your organization use an income-based qualifier such as the Federal Poverty Limit Guidelines to determine who is eligible to receive food assistance? * Yes No What are your eligibility guidelines? * What logistical capacities does your organization currently have? (Select all that apply):* * Dry/shelf stable storage Refrigerator storage Freezer storage Ability to pick up food from an NTFB distribution location (transportation) Storage in a temperature controlled, non-residential facility None of the above (Only same-day food distributions) If applicable, please further describe your storage space (including whether you have the ability lock your storage rooms): Please select the programs your organization is interested in: * Brick & Mortar - Providing groceries to those in need with one-time or short-term food assistance School Pantry - Providing kid friendly items to neighbors on a regular basis Senior Programs - Providing senior friendly items to neighbors on a regular basis Mobile Pantry - Providing fresh produce items at least once a month through just-in-time distributions Not Sure How would your organization utilize a partnership with Crossroads to increase impact to your neighbors? * If your organization had more resources, would you be willing to grow in capacity? If so, how?* * Where do you see the most need in your community? * How did you hear about Crossroads? * Media (TV, radio) Social Media Partner Referral Neighbor Referral Other Visit the Find Food tool on our website (https://ntfb.org/our-programs/get-food-assistance/find-a-food-pantry/). Please enter the name and distance of the nearest pantry to you: * Is your organization open to occasionally having SNAP outreach onsite?* * Yes No Would you be open to partnering with other providers in your area to offer non-food services? * Yes No Is your organization's information provided for 211? * Thank you!
