DigiMart Registration Form – General

    Welcome to Lutheran Social Services of Nevada!

    In order to receive DigiMart services for your household, please complete the intake form below. All answers will be kept confidential by LSSN staff members.





    Are you single or the head of household?







    If you are over 60 years of age, please complete our additional senior registration form here.








    Are you a veteran?



    Race (please select)



    Hispanic?



    Street Address






    If homeless, what is the ZIP Code of your last permanent address?



    Services Needed:
    Nutrition Education
    Specific Dietary Needs e.g. Boost/Ensure (when available)
    Employment Services e.x.: Resume, Online Job Searches, Applications
    Temporary Rental Assistance
    Hygiene Products
    SNAP Application Assistance
    Food Assistance
    Pet Food Assistance
    Birth Certificate Assistance
    Nevada ID Assistance
    Work Cards, Health Cards, Bus Passes
    Medicaid Application Assistance



    Please check all of your current sources of income below.
    Employment
    Unemployment
    SSI
    SSDI
    Worker's Compensation
    Private Disability Insurance
    Veteran's Benefits
    TANF
    Clark County Assistance
    Social Security
    Pensions/Retirement
    Child Support
    Alimony
    SNAP
    No income at this time



    Do you currently receive any of the following? (please select yes or no.)
    1.) Child Support

    2.) SNAP

    3.) WIC

    4.) Section 8 or Public Housing

    5.) NV Energy Assistance Program

    6.) Medicaid

    7.) Medicare

    8.) VA Medical Services

    9.) Nevada Check-Up

    10.) Child Care Assistance



    If there are additional individuals in your household, please complete the following. If there are no additional individuals in your household, please skip to the bottom and select "submit".



    Second Person:


    Relationship to you:



    If they are over 60 years of age, please have them complete our additional senior registration form here.
    Race (please select)

    Hispanic?

    Please check all of your current sources of income below.
    Employment
    Unemployment
    SSI
    SSDI
    Worker's Compensation
    Private Disability Insurance
    Veteran's Benefits
    TANF
    Clark County Assistance
    Social Security
    Pensions/Retirement
    Child Support
    Alimony
    SNAP
    No income at this time
    Attending School

    Approximate Monthly Income

    Are they disabled?

    Are they a U.S. Citizen?

    Place of Birth

    Please note their marital status below.
    Single
    Married
    Separated
    Widowed
    Live Together
    Highest Education Level




    Third Person:


    Relationship to you:



    If they are over 60 years of age, please have them complete our additional senior registration form here.
    Race (please select)

    Hispanic?

    Please check all of your current sources of income below.
    Employment
    Unemployment
    SSI
    SSDI
    Worker's Compensation
    Private Disability Insurance
    Veteran's Benefits
    TANF
    Clark County Assistance
    Social Security
    Pensions/Retirement
    Child Support
    Alimony
    SNAP
    No income at this time
    Attending School

    Approximate Monthly Income

    Are they disabled?

    Are they a U.S. Citizen?

    Place of Birth

    Please note their marital status below.
    Single
    Married
    Separated
    Widowed
    Live Together
    Highest Education Level





    Fourth Person:


    Relationship to you:



    If they are over 60 years of age, please have them complete our additional senior registration form here.
    Race (please select)

    Hispanic?

    Please check all of your current sources of income below.
    Employment
    Unemployment
    SSI
    SSDI
    Worker's Compensation
    Private Disability Insurance
    Veteran's Benefits
    TANF
    Clark County Assistance
    Social Security
    Pensions/Retirement
    Child Support
    Alimony
    SNAP
    No income at this time
    Attending School

    Approximate Monthly Income

    Are they disabled?

    Are they a U.S. Citizen?

    Place of Birth

    Please note their marital status below.
    Single
    Married
    Separated
    Widowed
    Live Together
    Highest Education Level





    Fifth Person:


    Relationship to you:



    If they are over 60 years of age, please have them complete our additional senior registration form here.
    Race (please select)

    Hispanic?

    Please check all of your current sources of income below.
    Employment
    Unemployment
    SSI
    SSDI
    Worker's Compensation
    Private Disability Insurance
    Veteran's Benefits
    TANF
    Clark County Assistance
    Social Security
    Pensions/Retirement
    Child Support
    Alimony
    SNAP
    No income at this time
    Attending School

    Approximate Monthly Income

    Are they disabled?

    Are they a U.S. Citizen?

    Place of Birth

    Please note their marital status below.
    Single
    Married
    Separated
    Widowed
    Live Together
    Highest Education Level


    Thank you for completing Lutheran Social Services of Nevada's intake form! A staff member will be reaching out to you soon to complete the intake process and to provide you with your unique user number, which will enable you to order food online.

    For any questions, e-mail Nutrition Services Manager Jocelyn Gonzalez-Rodulfo at jrodulfo@lssnv.org.



    Support our Mission
    Connect with Us
    Contact Us
    4323 Boulder Highway
    Las Vegas, NV 89121
    501(c)(3) nonprofit agency
    EIN Tax ID #86-0845241
    702-639-1730
    Hours of Operation

    DigiMart – Beginning 4/30/2020, DigiMart is open on Tuesdays and Thursdays between 8:00 a.m. and 11:00 a.m.

    Open Air Markets – Beginning 3/7/2020, all Open Air Markets have been temporarily postponed due to COVID-19.

    For an up-to-date schedule on the special Open Air Markets, check out our Facebook page at facebook.com/lssnv.

    As of 3/19/2020, all other services are available by appointment only. For more information, please call or e-mail info@lssnv.org.