Client Leadership Council Application, 3rd Class (2022-2023)

To amplify the voices of the people it serves, the Capital Area Food Bank convenes a Client Leadership Council (CLC) on an annual basis. The CLC brings together individuals with an array of perspectives and experiences from across the region, and seeks to empower members through a ten-month advocacy training program.

Please populate the information below to apply if you think you would be a good candidate to participate in the 3rd Annual CLC class!

CLC membership is ONLY available to individuals who are currently facing food insecurity or enrolled in social safety net programs, and who live in the Food Bank's service area. All the information in this survey is kept confidential to the Food Bank, and, in an effort to create a diverse class, the more information you are willing to share, the better we are able to assess whether you are a great fit for the program.

Please Note: applications for the 3rd Annual Class are being accepted July 5th-September 9th 2022. The class will formally run from late September 2022 - June 2023.

Contact Information

First Name Last Name

Date of Birth Preferred Language Pronouns

Gender Race

Street Address

Postal Code City State/Province

Email Mobile Phone

Sign me up for SMS messages.

By submitting your cell phone number you are agreeing to receive periodic text messages from this organization. Message and data rates may apply. Text HELP for more information. Text STOP to stop receiving messages.

Yes, sign me up for email updates.

(Optional)

Tell us about your lived experience and life story. What are some key events that have led you to where you are today? It is helpful to share obstacles, how they've shaped who you are today, and any food assistance you've used. (5-8 sentences)

Your Story

Additional Information

Demographic Information:

What County or Ward do you reside in?

What is your current work status?

Do you have a Social Security Number (SSN) or an Individual Taxpayer Identification Number (ITIN)?

What is your primary means of transportation?

What is your t-shirt size?

Do you have kids?

How many kids do you have, and what are their ages? (ex. One child age 5, or three children ages 5, 8, and 10. Write N/A if not applicable.)

Are you a single parent?

Do you receive child support or alimony?

Are you a grandfamily? (A household where the grandparents are the primary care providers for their children's children.)

Do you or does anyone in your immediate family have a disability? If so, please provide further details. (Write N/A if not applicable.)

Your Lived Experience:

Are you a veteran or currently serving in the military?

Is someone in your household a veteran or currently serving in the military?

Have you ever been incarcerated? If yes, for how long and why? (Write N/A if not applicable.)

Have you ever been homeless? If yes, when and for how long? (Write N/A if not applicable.)

What is the highest level of education you have completed?

Were you born in the United States?

If you were not born in the United States, where were you born and how long have you been in the United States? Please share a few sentences about your immigration journey.(Write N/A if not applicable.)

Your Experience with Food Assistance and/or Social Welfare:

(Reminder - In order to be eligible for the CLC, you must be currently experiencing food insecurity, receiving food from food assistance distributions or organizations, or using social welfare programs.)

Do you use SNAP (food stamp program)?

Do you use WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)?

Do you (or your children) use free/reduced price school meals (FARM, National School Breakfast/Lunch program)?

Do you use the Earned Income Tax Credit (EITC, Working Families Income Supplement)?

Do you use the Child Tax Credit (CTC, CHILDCTC)?

Do you use TEFAP ( The Emergency Food Assistance Program)?

Do you use TANF (Temporary Assistance for Needy Families, Temporary Cash Assistance)?

Do you use Medicaid?

Do you use the Medicare Savings Program (QMB/Qualified Medicare Beneficiary, SLMB/Special Low-Income Medicare Beneficiary)?

Do you use SSI/Supplemental Security Income?

Do you use utility/energy assistance (LIHEAP, MEAP, EAP)?

Do you use SSDI/Social Security Disability?

Do you use housing vouchers/subsidies?

Do you use Rapid Re-Housing?

Do you receive free food from food assistance distributions or nonprofit organizations?

How often do you receive free food from food assistance distributions or nonprofit organizations? (Write N/A if not applicable.)

What are the names of the nonprofit organizations or food assistance distributions that you receive free food from? (Write N/A if not applicable.)

If you have dietary restrictions/preferences, please list them below (write N/A if not applicable):

Technology and Communication:

Do you have wifi?

Do you have a computer?

Do you have a cell phone with internet access?

Are you able to use Zoom? (You are able to download the app onto your computer or cell phone and log-in to the platform successfully?)

What is your preferred method of communication?

More About Your Story:

How has the pandemic affected your livelihood and well-being? (3-5 sentences)

If you were a superhero, what would your superpower be and why?

How did you hear about the CLC?