Food Bank Application

We accept applications from those residing in Bothell, Lynnwood, Kenmore, Mill Creek, and those with 98208 & 98296 zip codes, as well as anyone who has a child in the Northshore School District, with proof.
No location restrictions apply for Canyon Hills Community Church members or regular attendees.

After the application is filled out, required documents must be turned in before an interview can be scheduled. Please note the entire application process can take up to two weeks.

Your name *

Last name

Email address *

Phone number *

Phone type

Address *

Country

Street Address

Apt/unit/box (optional)

City

State

Postal code

Birthday *

Gender *

Marital Status *

Single

Married

Divorced

Widowed

What language do you speak? *

(Ex. English, Arabic, Farsi, Spanish, etc.)

How many people are you hoping to shop for? *

(Ex. 5 people, 2 people, etc.)

Household Information

Children in the Home *

Name, Birthdate (Ex. Jill, 01/01/2001)

Other Residents *

Please list the name and age of anyone else residing in the home. As well as reason they are residing in your home. If no one, please put "N/A"
(Ex. Jill Smith, 92, grandmother)

Financial Information

Your Occupation *

Your Employer *

Your Monthly Income *

Your Second Occupation and Employer

(If applicable)

Your Second Monthly Income

(If applicable)

Please explain any employment issues. (Such as: unemployment, moved, illness, currently laid off, etc.) *

Expenses

Please list your monthly expenses below

Rent/Mortgage *

Utilities *

Gas, Electric, Water, Trash, Sewer

Insurance *

Health, Auto, Renters', etc.

Car(s) (Make/Model/Year) *

Ex. Toyota / Rav-4 / 2010

Car Payment(s) *

Please indicate the payment for each vehicle. If you have no car payment, put "n/a"
(Ex. SUV- $100 a month)

Credit Card(s) *

Include balances and past due amount. If none, put "n/a"

Phone/TV/Internet *

Monthly Amount

Medical Bill(s) *

Include balances and past due amount. If none, put "n/a"

Financial Assistance

Please indicate any other financial assistance you or household members are currently receiving *

Unemployment

Food Stamps

DSHS (e.g. SNAP, Apple Health, TANF)

Section 8

Social Security

Disability

None of the above

Other

Please indicate the amount you receive through the above financial assistance programs. *

If this does not apply, please type "N/A"

Have you applied for the Food Bank or Aid+Assitance from Canyon Hills Community Church before? *

Do you currently receive child support? *

Yes

Church Information

How did you hear about CHCC? *

Please indicate which category you fall into *

Not attending: Non-Attendee

Attending Canyon Hills Community Church: Attendee

Member of Canyon Hills Community Church: Member

Are you currently in a Life Group at Canyon Hills? *

Are you currently involved in a ministry at Canyon Hills? *

Have you been helped by your church, another church, or another organization? *

Are your family members aware of your financial situation? *

Please use the space below to tell us about your need, circumstance that caused the need, and any additional information you think may be of importance in considering your request. *

Review and Sign

Please read these carefully before signing.

I hereby verify that the information in this application is accurate, and I give my consent to Canyon Hills Community Church to share the information contained in this form with other churches and/or agencies *

Please sign by typing your name and the date

We look forward to serving you and sharing God’s love for you in this tangible way!

We consider it a privilege to serve you in this way. Please accept this food as a gift from the Lord, and as a gift from our congregation. Our prayer is that you will feel loved by us and the Lord. If you do not know Jesus as your Lord and Savior, anyone serving in the Food Bank would love to talk with you about how you can make that life changing decision!

Client Guidelines

Please read the following guidelines carefully! *

1. OUR GOAL is to provide you with enough food for your family for the week.

2. Food Bank Sequence: Each week you will follow the itinerary listed below:
• You will stop at the Check-In Desk to receive a card labeled with your name and the number of persons in your family.
• Your next stop will be our Hospitality Room, where you can enjoy some refreshments. One of our volunteers will spend some time visiting with you and praying for you.
• When it’s your turn, another volunteer will guide you through our Food Rooms. While shopping we ask that you accept the direction of your shopping volunteer. These volunteers are trained to assist and instruct you through the food rooms.
• After shopping, you will drive around to the back of the Warehouse where our volunteers will load your groceries into your car.

3. Arrival and Shopping:
• Please arrive before 1:15 for our first session or 6:45PM for our second session. If you arrive late, you will not be able to shop.
• Only you (or an approved member of your family) are eligible to shop (1 person per family in the shopping room). Prior arrangements must be made if you need someone else to shop for you or with you.
• Please dress appropriately and cease to use any foul language while attending.

4. Accepted clients may use the Food Bank during a period of 3-6 months. After that time, the client file will need to be updated, by the client, and then reviewed to determine if further use of the Food Bank is necessary. We ask that you notify us of any changes in your financial status or your dependents eligibilities as soon as possible, even prior to review. Our leadership reserves the right to extend or deny your use of the Food Bank as deemed necessary.

5. We reserve the right to discontinue your use of our food bank if you are dishonest, steal from us, arrive at the food bank on drugs or inebriated, or for any reason we deem necessary for the safety of others or for the proper functioning of the Food Bank. We respect you, and we ask that you be respectful of our volunteers serving you, and your fellow food bank clients.

Please write your name and the date below if you understand and agree to abide by the above guidelines.

Liability Waiver *

Most of the food and non-food items that the food bank distributes are donated. We can’t check every item that we receive. Please inspect all the food and non-food items which are given to you.

I agree to hold harmless the Canyon Hills Community Church Food Bank, any other organizations and other individuals who support or assist the food bank for any injury or illness caused by distribution to, consumption of, or use of food or other items by me, my family or other individuals.

By signing below, I acknowledge that I have read and understand the provision of the liability waiver described above.

Required Documents

All required documents must be turned into our office or emailed to foodbank@chccbw.org for your application to be considered complete. Once we receive all these documents we will set up an interview with you.

Applications will not be accepted without all documents.

Required Documentation:
☐ Photo ID of all adult clients (Driver’s license/passport; current & valid)

☐ Dependents: (1 document for each dependent)
a. Children under 18 – birth certificate(s) or current school year enrollment(s)
b. Children 18-25 – birth certificates AND proof of current year school enrollment
c. Children over 18 but are not enrolled in school do not qualify as dependents.

☐ Home address: established for all persons 18 years and older
a. Signed & dated rental/lease agreement, current utility bill, or any business mail addressed to the client or the client’s dependent(s)
b. Each person must prove they live at the address. No exceptions.

☐ Income: established for each and every adult working or receiving income
a. Current pay stub, unemployment pay stub, and/or proof of any government aid such as DSHS, WIC, SSI, food stamps, etc.
b. If employment is paid by check/cash, turn in a current bank statement or a signed/dated letter from the employer.
c. Please include any child support, alimony, or any other private financial assistance that you receive.

If you have any questions, please contact us.

Call: 425-488-4121
Email: foodbank@chccbw.org

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Canyon Hills Community Church
info@chccbw.org
425-488-4121