1.What is your name? 

2.What is a good contact number for you? 

3.Are you able to attend the distribution on August 25th between 5:30pm and 7pm?

Yes

No

4.If you can not attend we will contact you to set up another time. Please provide the best contact if different from what is listed above. 

5.If you are getting groceries please tell us how many people are in your family.

6.Is there anything else you are in need of that you would like to share?