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2. Bayfield County Department of Human Services
4. This registration form should be filled out, printed, and brought to your first meal pick-up. Your information will not be saved or submitted online.
6. Date of Registration*
   Date of Registration
7. Date of Birth*
   Date of Birth
8. Gender

   1. Male
   2. Female
9. Telephone Number
11. Name (First, MI, Last)*
13. Residential Address (Fire no. and Street)*
15. City/State/Zip
17. Race

    1. American Indian or Native Alaskan
    2. Asian or Asian American
    3. Black or African American
    4. Native Hawaiian of Pacific Islander
    5. White (non-Hispanic)
    6. White-Hispanic
    7. Other
18. Ethnicity

    1. Hispanic or Latino
    2. Non Hispanic or Latino
19. Is your income below the following Federal Income Guidelines?

    1. Yes
    2. No

    Federal Income Guidelines:

    1 person in home : $1,063/month, $12,760/year

    2 people in home: $1,437/month, $17,240/year

    3 people in home: $1,810/month, $21,720/year

    4 people in home: $2,183/month, $26,200/year

21. Nutrition Risk Screening Questions:

    I have an illness or condition that made me change the kind and/or amount of food I eat.

    1. Yes
    2. No
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