LRCA Food Bank Registration Form

Ladysmith Resources Centre Association > Programs > Food Security > LRCA Food Bank > LRCA Food Bank Registration Form

Thank you for filling out this form in advance.

On your first visit, please be prepared to show Care Cards for each family member. Proof of address will also be needed.

Just a note: Inactive Food Bank registrations are valid for six months.

Food Bank Registration Form

Card Member Name *

First

Last

Gender

Male
Female
Other
Prefer not to answer

Date of Birth *

Your Birthdate

Address / Living Situation *

Where are you staying?

Postal Code *

Phone Number

Marital Status

Single
Married
Common-Law
Divorced
Separated
Widowed

Spouse/Partner Name

First

Last

Spouse Date of Birth

Spouse Gender

Male
Female
Other

DEPENDENTS (live with you)

First

Last

Dependent 1 Date of Birth

Dependent 2

First

Last

Dependent 2 Date of Birth

Dependent 3

First

Last

Dependent 3 Date of Birth

Dependent 4

First

Last

Dependent 4 Date of Birth

Dependent 5

First

Last

Dependent 5 Date of Birth

Dependent 6

First

Last

Dependent 6 Date of Birth

How did you hear about the LRCA Food Bank?

How long have you lived in Ladysmith?

I am new to Canada

If yes, when did you arrive?

I can get to and from the food bank without help

I can come to the food bank regularly on Tuesday evening or Wednesday morning

If no, why not?

If no, what day and time could you come to the food bank regularly?

I am a Post-Secondary student

I am

First Nation
Metis
Inuit
Other

My home is

Band owned
On the street/in the shelter
Supported Living
With family or friends
Rental
I own my home

Main source of income

Full time work
Part time work
Seasonal employment
Social assistance
Strike pay
Medical EI
EI
WCB
Old age/Canada pension
No income

Spouse main source of income

Full time work
Part time work
Seasonal employment
Social assistance
Strike pay
Medical EI
EI
WCB
Old age/Canada pension
No income

Search

Contact

Location: 630 2nd Avenue, Ladysmith, BC
P: 250-245-3079
F: 250-245-3798
Monday to Thursday, 9:00 a.m. to 3:00 p.m.
Closed Friday, Saturday, Sunday
Get in touch via email »

Mailing
P.O. Box 1653, Ladysmith, BC, V9G 1B2

Sign up for our Newsletter

Latest News & Events

Beatlemania steals the show as LRCA concerts hit the stage again
LRCA Affordable Housing Project: Facts for You/FAQs
July 14th 2022: Notice of Adjourned General Meeting
July 14th 2022: Proposed Agenda- Adjourned Extraordinary Meeting
Notice explains adjournment of June 14 extraordinary meeting