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 2

PEAS

BROCCOLI (2)

MIXED VEGETABLES (2)

PEPPERS & ONIONS

STRAWBERRIES

PEACH CUPS (4)

WAFFLES

CORN

FRENCH FRIES

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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

MIXED VEGETABLES

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* 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT

APPLESAUCE

MIXED FRUIT

PEACHES

APRICOTS

PEARS

NONE

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* 8. PLEASE CHOOSE 1 CAN of MEAT

TUNA

PORK

CHICKEN

SALMON

BEEF

NONE

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* 9. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP

CHICKEN W/ RICE

ONION SOUP

CREAM OF MUSHROOM

CREAM OF CHICKEN

CORN CHOWDER

TOMATO

VEGETABLE

CHICKEN NOODLE SOUP

GARDEN VEGETABLE WITH PASTA

BEEF STEW

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* 10. PLEASE CHOOSE UP TO 8 DRY GOODS

RICE

SPAGHETTI NOODLES

MACARONI AND CHEESE (2)

RAMEN NOODLES

MASHED POTATOES

HAMBURGER HELPER OR LIKE FLAVOR

SCALLOPED POTATOES

OATMEAL

CEREAL (1)

GRANOLA BARS

PANCAKE MIX

PECANS

HAZLENUTS

WALNUTS

FRUIT AND NUT MIX

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* 11. PLEASE CHOOSE 1 DRINK

GROUND COFFEE

K CUPS

JUICE - BOTTLED

JUICE BOXES

None of the above

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* 12. PLEASE CHOOSE UP TO 6 CHOICES

TOMATO/SPAGHETTI SAUCE

STUFFING MIX

CHEF BOYARDEE (2)

GRAVY

CHILI - NO BEANS

PEANUT BUTTER (1)

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

PANCAKE SYRUP

SLOPPY JOE MIX

BOXED DESSERT MIX OR PUDDING MIX

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* 13. PLEASE CHOOSE 2 DAIRY OPTIONS.

EGGS (1dozen)

MILK

CHEESE

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* 14. PLEASE CHOOSE 2 MEATS

HOT DOGS (2)

BABY BACK PORK RIBS

RACK OF LAMB

CHICKEN DRUMSTICKS

CHICKEN BREASTS

CHICKEN QUARTERS

HAM STEAKS (2)

GROUND BEEF (2)

GROUND TURKEY (2)

FISH FILLETS

PORK CHOPS

FISH STICKS

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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 2

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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 1 CAN of MEAT

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* 9. PLEASE CHOOSE UP TO 2 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 6 CHOICES

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* 13. PLEASE CHOOSE 2 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!