CHOICE FOOD PANTRY - Household size of 5 or more Survey

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* 1. PLEASE PROVIDE THE FOLLOWING INFORMATION

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. WHICH SCHOOL DISTRICT DO YOU RESIDE IN?

RED LION

DALLASTOWN

EASTERN YORK

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* 3. HOW MANY PEOPLE RESIDE IN YOUR HOUSEHOLD? If you have 5 or more continue with this form. If 1-4 , please complete the other food pantry choice form.

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* 4. PLEASE TELL US HOW MANY HOUSEHOLD MEMBERS ARE IN EACH AGE GROUP BELOW

CHILD (AGES 0-17)

ADULT (AGES 18-59)

SENIORS(AGES 59 AND OVER)

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* 5. FREEZER CHOICE - CHOOSE 1

SWEET POTATO FRIES

BROCCOLI

STRAWBERRY TOASTER PASTRIES

PEPPERS & Onions

BROCCOLI

CORN

FRENCH FRIES

FRIED CHICKEN w/ MASHED POTATOES

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* 6. PLEASE CHOOSE 3 TYPES OF CANNED VEGETABLES

WHOLE CORN KERNALS

GREEN BEANS

PEAS

BEANS - May be kidney, pinto or garbonzo

SLICED POTATOES

SPINACH

CARROTS

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* 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT

APPLESAUCE

MIXED FRUIT

PEARS

PEACHES

NONE

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* 8. PLEASE CHOOSE 2 CAN of MEAT

TUNA

CHICKEN

SALMON

BEEF

NONE

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* 9. PLEASE CHOOSE UP TO 3 DIFFERENT CANS OF SOUP

CHICKEN W/ RICE

CREAM OF CHICKEN

SEAFOOD BROTH

TOMATO

VEGETABLE BEEF

CHICKEN NOODLE SOUP

ONION DIP AND SOUP MIX (DRY)

BEEF STEW

CREAM OF MUSHROOM

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* 10. PLEASE CHOOSE UP TO 8 DRY GOODS

RICE

SPAGHETTI NOODLES

MACARONI AND CHEESE (2)

HAMBURGER HELPER OR LIKE FLAVOR

TUNA HELPER

OATMEAL

CEREAL (2)

PECAN PIECES

PANCAKE MIX

GRANOLA BARS

Scalloped Potatoes

ALMONDS

ELBOW NOODLES

TACO SHELLS

CANNED SLOPPY JOE SAUCE

RAISINS

HAZELNUTS

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* 11. PLEASE CHOOSE 1 DRINK

TEA BAGS

JUICE

NONE

DECAF COFFEE

None of the above

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* 12. PLEASE CHOOSE UP TO 8 CHOICES

TOMATO/SPAGHETTI SAUCE

DICED TOMATOES/CRUSHED TOMATOES

RAMEN NOODLES

PEANUT BUTTER (2 jars or 1 large)

MISC CONDIMENTS - May include one of the following: MAYO, SALAD DRESSING, KETCHUP, MUSTARD

PANCAKE SYRUP

PIZZA DOUGH

PIZZA SAUCE

BOXED PASTA SIDE DISHES

CANNED SLOPPY JOE SAUCE

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* 13. PLEASE CHOOSE YOUR DAIRY OPTIONS

EGGS (2 dozen)

MILK

CHEESE

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* 14. PLEASE CHOOSE 2 MEATS

HOT DOGS (2)

CHICKEN BREASTS

CHICKEN DRUMSTICKS

GROUND BEEF (2)

SALMON

SAUSAGE

FISH STICKS

CATFISH

HAM STEAKS - after 10/8

WHOLE FROZEN TURKEY

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* 15. DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS

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* 16. DUE TO THE HIGH VOLUME OF CLIENTS WE ARE NOW SERVICING, WE MAY NOT BE ABLE TO ANSWER THE PHONE OR RETURN CALLS UNTIL THE NEXT BUSINESS DAY. IF YOU HAVE QUESTIONS OR CONCERNS PLEASE SEND AN EMAIL TO OFFICE@COMMREACH.ORG

Yes

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* 17. DO YOU HAVE A BABY CLUB PICKUP WITH THIS ORDER?
IF YOU WOULD LIKE TO REGISTER FOR OUR BABY CLUB PLEASE VISIT OUR WEBSITE. YOU MUST SUBMIT A BIRTH CERTIFICATE OR GUARDIANSHIP DOCUMENTS PRIOR TO YOUR FIRST BABY CLUB PICKUP.
EACH AND EVERY MONTH YOU MUST SUBMIT THE BABY CLUB REQUEST FORM ON OUR WEBSITE.

Yes

CHOICE FOOD PANTRY - Household size of 5 or more

COMMUNITY REACH INC FOOD PANTRY FOOD CHOICES

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* 1. PLEASE PROVIDE THE FOLLOWING INFORMATION

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* 2. WHICH SCHOOL DISTRICT DO YOU RESIDE IN?

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* 3. HOW MANY PEOPLE RESIDE IN YOUR HOUSEHOLD? If you have 5 or more continue with this form. If 1-4 , please complete the other food pantry choice form.

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* 4. PLEASE TELL US HOW MANY HOUSEHOLD MEMBERS ARE IN EACH AGE GROUP BELOW

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* 5. FREEZER CHOICE - CHOOSE 1

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* 6. PLEASE CHOOSE 3 TYPES OF CANNED VEGETABLES

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* 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT

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* 8. PLEASE CHOOSE 2 CAN of MEAT

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* 9. PLEASE CHOOSE UP TO 3 DIFFERENT CANS OF SOUP

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* 10. PLEASE CHOOSE UP TO 8 DRY GOODS

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* 11. PLEASE CHOOSE 1 DRINK

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* 12. PLEASE CHOOSE UP TO 8 CHOICES

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* 13. PLEASE CHOOSE YOUR DAIRY OPTIONS

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* 14. PLEASE CHOOSE 2 MEATS

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* 15. DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS

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* 16. DUE TO THE HIGH VOLUME OF CLIENTS WE ARE NOW SERVICING, WE MAY NOT BE ABLE TO ANSWER THE PHONE OR RETURN CALLS UNTIL THE NEXT BUSINESS DAY. IF YOU HAVE QUESTIONS OR CONCERNS PLEASE SEND AN EMAIL TO OFFICE@COMMREACH.ORG

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* 18. DOES ANYONE 12 AND UNDER IN YOUR HOUSEHOLD HAVE A BIRTHDAY THIS MONTH? IF SO, PLEASE LIST THEIR NAME AND DOB. THIS IS FOR CHILDREN ONLY!