Food Delivery Program - Walmart » LifeCare Alliance

Client Information

First Name*

Last Name*

Date of Birth*

Client Home Zip Code*

Client will need a translator*

Yes

No

Primary Language Needed?

Race*

American Indian and Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Racial Subgroup

Ethnicity*

Hispanic

Non-Hispanic

Hispanic/Latino(a) Subgroup

Gender*

Male

Female

Transgender Male to Female

Transgender Female to Male

Transgender Other

Unknown

Sex Assigned at Birth*

Male

Female

Client Contact Information

LifeCare Alliance will contact the client based on this information.

Phone*

Client is solely responsible for timely communication with LifeCare Alliance. Failure to communicate with LifeCare Alliance will affect client’s ability to obtain grocery delivery. Client must also be within the grocery delivery area to receive grocery delivery

Email*

Delivery Address*

Street Address Address Line 2 City ZIP / Postal Code

Choose One Eligibility Below*

Part A Eligibility

EHE Eligibility

To be EHE eligible, client must currently be in an EHE program or have graduated from Columbus TGA EHE or Part A services.

Approval Date*

Expiration Date*

Designated Ryan White Part A or EHE Professional

Name of Professional*

Agency Name*

Email*

Phone*

Any additional important information we need to know about this client?

Consent*

By signing this form, I certify that all information given on this form is truthful to my knowledge. I understand I must submit this request on behalf of the Columbus TGA Part A or EHE eligible client to LifeCare Alliance on or before February 29, 2024. I have informed the client that food delivery is on a first come, first served, limited basis, as received by distributing agency as funds are available.

I Agree

Please upload Release of Information (ROI) Form here if applicable.

Drop files here or

Max. file size: 5 MB.

Ryan White Part A and EHE

Eddie Hamilton’s Food Delivery Program
Client Authorization Form

Client Information

Client Contact Information

Designated Ryan White Part A or EHE Professional

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Ryan White Part A and EHE

Eddie Hamilton’s Food Delivery Program Client Authorization Form

Client Information

Client Contact Information

Designated Ryan White Part A or EHE Professional

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Donate

Volunteer

About

Programs

Locations

Eddie Hamilton’s Food Delivery Program
Client Authorization Form