CoVID Help Application

Move On Up, Mississippi wants no Lafayette County child to go hungry. We want no Lafayette County family to go without food. If you have lost your job because of this public health crisis, been quarantined under a doctor’s order, or been doctor diagnosed with COVID19, we want to help with access to food. Please complete the following application.

Household Information
Your Name*
First Last
Your Adult Partner's Name
First Last
Please list the members of your household.*
Include name, age, and allergies of each household member.
Your Address*
Street Address Address Line 2 City State ZIP Code
Your Phone Number*
Your Email*
Enter Email Confirm Email
Your Circumstances
Reason for loss of employment or deduction of hours (Please select one).*
- Public Health Crisis - employer's decision
- Doctor's Ordered Quarantine
- Doctor's Diagnosed CoVID-19
Please describe your situation.
Employer Information
Employer*
Employer Contact Name
First Last
Employer Phone*
Employer Email

Household Information

Your Circumstances

Employer Information

Move On Up Mississippi