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New Registration For Food Pantry Services
New Family Pantry Registration
Registration For Food Pantry Services
OK
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1.
Have you received food from our food pantry in the past 4 months?
IF SO, you may exit this survey. Please do not complete this registration. You are already registered. We have received many registrations from our current pantry families and it is not necessary.
IF NOT, please continue and complete this registration so that you can use our services.
(Required.)
I need to continue this registration because I will be new to the food pantry at Community Reach Inc.
I need to exit. I already receive food from the food pantry at Community Reach Inc.
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2.
Please provide the following information.
(Required.)
First and Last Name
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Address
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City/Town
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State/Province
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
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Email Address
Phone Number
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3.
We currently only service families living in the Red Lion, Dallastown, or Eastern School Districts. You must live in one of those school districts to register to use our pantry.
What school district do you live in?
(Required.)
Red Lion Area School District
Dallastown School District
Eastern York School District
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4.
How many people live in your household?
(Required.)
Seniors (Age 60 or older)
Adults (Ages 18-59)
Children (Ages 0-17)
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5.
Does anyone in your household have any allergies? If so, please provide details.
(Required.)
*
6.
You must provide the following information for each household member
Household Member 1- Yourself
(Required.)
First and Last Name
DOB
Gender
Age
7.
You must provide the following information for each household member
Household Member 2
First and Last Name
DOB
Gender
Age
8.
You must provide the following information for each household member
Household Member 3
First and Last Name
DOB
Gender
Age
9.
You must provide the following information for each household member
Household Member 4
First and Last Name
DOB
Gender
Age
10.
You must provide the following information for each household member
Household Member 5
First and Last Name
DOB
Gender
Age
11.
You must provide the following information for each household member
Household Member 6
First and Last Name
DOB
Gender
Age
12.
You must provide the following information for each household member
Household Member 7
First and Last Name
DOB
Gender
Age
13.
You must provide the following information for each household member
Household Member 8
First and Last Name
DOB
Gender
Age
*
14.
Are you or anyone else in your household currently employed?
(Required.)
Full Time
Part Time
Retired
Unemployed or Disabled
*
15.
Do you or anyone else in your household receive SNAP benefits? (your registration will not be effected whether or not you receive SNAP benefits)
(Required.)
Yes
No
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16.
Are you currently homeless or live in temporary housing? If so, please contact us directly at 717-244-6934 to receive an emergency food box and to let us know if you have restrictions on what type of food you can receive based on whether or not you have access to a refrigerator and stove.
(Required.)
Yes- I am homeless or I live in temporary housing
No-I am not homeless and I have a permanent residence
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17.
After completing this registration, please visit the Pantry Services page on our website to schedule your food pick up. Please schedule your food pick up at least 2 business days from today.
(Required.)
I will
I will wait until later to schedule my food pick up
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18.
If you need to change or cancel your appointment, you can cancel or change your appointment up to 12 hours prior to your appointment time using the same link that you used to schedule your appointment. If it is under 12 hours please call us directly.
We do ask that you cancel at least 24 hours prior to your scheduled appointment time.
(Required.)
I understand
I don't understand
*
19.
Would you like to a proxy (someone outside of your household) pick up your monthly food box if you are not able to? If so, please list their name and phone number.
(Required.)
*
20.
You are allowed to pick up food once a month. If there is an emergency situation and you need extra food, please contact us directly.
(Required.)
Yes
No
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