Apply for Services

Indicates required field

Warning message

×The information provided may be shared with partner organizations for the purpose of processing this application, including Edmonton Food Bank and the Salvation Army.

Information message

Please fill out the form to the best of your ability. If you require help, please contact us.

In order for your application to be considered we require your address, phone number, and the names, gender and birth dates of all residents. The household name will be the name of a "primary resident", typically the person filling out this form.

Application information

Primary Resident

Enter the name, gender and birth date for the primary resident of the household.

First Name

Last Name

Gender

Female

Male

Other

Birth Date

Note: Future dates will not be accepted.

Phone

Primary Phone Number

The primary number we can use to contact you.

Cell Phone Number

Re-enter if same as primary.

Email information

Enter the primary email address we can use to contact you.

Delivery address

Street Address

City

Apartment / Unit #

Apartment/Unit Buzzer

Please provide a buzzer number if there is an apartment unit, otherwise please leave it blank. (This field is required if a unit is provided.)

Postal Code

Enter a Canadian postal code in the format of H0H 0H0.

Province

Country

Delivery instructions

Provide details needed for delivery.

My mailing address is different from my delivery address

Select to enter a mailing address if it is different from the delivery address.

Mailing address

Street Address

City

Apartment / Unit #

Supplemental address information

Add supplemental information such as Buzzer or Delivery Instructions.

Postal Code

Enter a Canadian postal code in the format of H0H 0H0.

Province

Country

Household information

The name and contact details for your household. The household is all residents living in the same residence.

Household Name

The household name is set to be the full name of the primary resident. It will be updated automatically if the primary resident name is updated.

Household size

Please include the number of people living in your household throughout the year. Note: If you have family or friends visiting during the holidays you do not need to include them in your total.

Other Household Residents

Add more residents in this household if there are any, aside from the primary resident. Provide name, gender and birth date for each resident.

If a baby is expected to be born by December 31 of the current year, please add the child as a resident and the expected due date.

Click Add to add a resident, or edit an existing resident if it is prepopulated. Any existing resident removed from this list will be removed from the household.

Residents

Information message

No residents entered. Please click Add below to provide residents.

Household Income

Monthly Income per resident

Required. Enter the monthly income per source of each adult resident. At least one income source is required for each resident over the age of 17, even if their income is zero. If an adult has multiple income sources then enter each income source on a separate line (with the resident's name each time).

Resident	Income source	Income ($)	Operations
Resident Name of the resident who receives the income.	Income source Income source for this resident.	Income ($) Monthly income in dollars.

Preferences

Service preference(s)

Check all that apply. Selecting "Food" will display a second set of options.

Food

Gift card for youth 13-17 years

Food preference

Choose how you prefer to receive the food gift. The hamper cannot be customized so if you have specific needs or requests please choose the gift certificate option.

Hamper

Gift certificate

Electronic Gift card

Sorry, there are no more Hampers available please choose a Gift card instead.