OW Registration Intake Form – Halton Food Connect

First Name *

Last Name *

Email *

If your client does not have an email address please use the following format: SAMSID@haltonfoodconnect.ca.

Account Password *

Phone Number *

Ontario Works Member ID *

Your member ID# (MID#) is 9-digits long and starts with a 1, 2 or 3 and can be found on most correspondence from Ontario Works.

Are you a resident of Halton Region? *

Yes
No

Are you a recipient of assistance through Ontario Works? *

Yes
No

Delivery Information Heading

Delivery Information

Housing Type *

Buzzer # or Entry Code

Street Address *

Apartment/Unit Number

2nd Street Address

City *

Province *

Postal Code *

Delivery Times

Please check the days when you are available to receive a delivery. You will need to be physically present to receive your package. Delivery times and days are not guaranteed but will be considered when planning deliveries.

Possible Delivery Day *

Please choose a minimum of three dates.

Preferred Delivery Windows *

Morning (8:00am-12:00pm)
Afternoon (12:00pm-4:00pm)
Evening (4:00pm-8:00pm)

Delivery Instructions

Please let us know any other information or instructions regarding your delivery.

Food Choices and Dietary Considerations Heading

Food Choices and Dietary Considerations

Choose Your Protein *

You are able to change this from month to month.

Would you like to add a produce bundle to your monthly protein delivery? *

A photo of a box of groceries on a counter.

A produce bundle is a mixed assortment of fruits and vegetables. Monthly contents vary based on seasonality and availability of products, and therefore cannot be customized.

Yes
No

Dietary Considerations

Please note that we are not a nut free, gluten free, dairy free, soy free or egg free facility. We will do our best to accommodate any needs indicated, but cannot make guarantees.

OW Employee Name Completing Registration

Registration Message

By submitting this form you are registering for the Halton Food Connect program and agree that you are aware of the Terms of Service and Privacy Policy.

You may login to your account at any time to make changes to your address, contact information and food preferences.