GAP Online Application

First name

Last name

Phone

Email

Multi-line address

Country/Region

Address

City

Zip / Postal code

Name of person assisting with form (if applicable):

Have you had a brain injury?

Yes

No

Which region do you live in?

Northern Kentucky

Cincinnati

Southeastern Indiana

Other

Which most closely resembles your situation?

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

I am able to drive to the grocery store and shop for groceries. I can shop for my own groceries or have someone load groceries into my vehicle.

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

Yes

No

Kroger Boost Enrollment

Please upload proof of enrollment in the Essential Kroger Boost program ($69/year subscription)

Signature

Signature field is empty.

Contact Us