Grocery Delivery Assistance Application

Name of Person Requesting Assistance

Today's Date

Email

Address

Phone

Name of person assisting you (if applicable)

1. Have you had a brain injury?

Yes

No

2. Are you the primary caregiver for a person who has had a brain injury?

Yes

No

3. Do you live in one of the following regions:

Northern Kentucky

Cincinnati

Southeastern Indiana

4. Please select one of the following that most closely resembles your situation:

Driving to the grocery store and obtaining the groceries presents a hardship. Having the groceries delivered to my door would help reduce the hardship.

I am able to drive to the grocery store and shop for my own groceries. I can load my own groceries into and out of my car or have someone do it for me.

5. Would you or a caregiver be able to use the Kroger app to order groceries?

Yes

No

Grocery Delivery Assistance Application

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