SHARE FOOD PROGRAM
Host Application Form

To become a Share Host, fill in the form below then click Submit Form.  If you do not know an answer to a question, leave it blank and we will follow up with you.
   
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Host Organization Information
Organization City
Street County
State
If your state is not listed above, do not fill in this form!		 Zip
Host Coordinator
Name Cell Phone
Day Phone Evening Phone
Fax Email
Mailing address if different from above.
Distribution Site if different from above.

Referral Information

 Would you like to accept Food Stamps Yes   No

Team Members

Registration Coordinator

Trucking / Distribution Coordinator
Name Name
Address Address
Day Phone Day Phone
Evening Phone Evening Phone

Statement of Participation

We wish to participate in the Share Food Program, serving both registration and distribution points for the food packages.  As a participating Host, we certify the following:

1.  We will not charge more then $15 or the designated price for the food package.
2.  Food will not be resold, and will be distributed to those who have paid for each package.
3.  We will encourage and provide opportunities for participants to fulfill their two hours of community service requirement including sending participants to Share Center.
4.  We also understand that if we wish to stop participating in the SHARE Food Program, we will give 30 days notice and honor a transitional period of three months.  During this period, SHARE and the discontinuing Host Site will work collaboratively to identify potential Host Sites in the community and/or determine appropriate referrals to existing Host Sites.
5.  We understand that the purpose of this arrangement is to offer continuous support to SHARE participants.
I have read the Statement of Participation above and understand that entering my initials in the box below is the same as signing my name.
CLICK THIS BOX è     I Agree
Initials Title
Date