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Manna’s Market Intake Form

 
Manna’s Online Market Intake Form 2022

Welcome to Manna's Market Online Intake Form. Manna provides groceries to households living in Montgomery County. We will need to verify your address at your first shopping appointment. Please see the below list of items needed for Address Verification.

Primary Shopper

xx/xx/xxxx
Primary Language
Did you hear about Manna through ACLAMO?
Did you hear about Manna through North Penn School District?

Other Adults in Household

Other Adult

xx/xx/xxxx
Add Remove

Minors in Household (Under 18)

Minor in Household

xx/xx/xxxx
Add Another Minor Remove A Minor

Address Verification

As part of our address verification process, the primary shopper will be asked to show their photo ID and one of the following items at their first Market shopping trip. (A current lease, a current bill, a current pay stub from an employer, a bank statement that shows your address, a current piece of official mail related to benefits such as health insurance, SNAP, Social Security, etc.). *
Manna on Main Street will safeguard your personal information. In certain situations, we may need to contact other organizations to obtain or share information to better assist you. Your information will only be used within the scope of our services for food assistance and for rental, utility or other financial assistance. Note that signing this form gives Manna permission to text or email you updates. *
Manna does not discriminate based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted. *