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 hace 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

ONIONS

CORN

GREEN BEANS

STRAWBERRY CUPS

BROCCOLI

HAM & CHEESE BREAKFAST SANDWICH

STIR FRY VEGETABLES

PEPPER AND ONION BLEND

DICED SWEET POTATOES

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* 6. PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES

WHOLE CORN KERNALS

GREEN BEANS

PEAS

BEANS - May be kidney, pinto or garbonzo

SLICED POTATOES

SPINACH

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* 7. PLEASE CHOOSE UP TO 3 CANNED FRUIT

APPLESAUCE

MIXED FRUIT

PEACHES

PEARS

NONE

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* 8. PLEASE CHOOSE 2 CAN of MEAT

CHICKEN

SALMON

BEEF

PORK

NONE

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

BROTH - CHICKEN OR BEEF

CHICKEN W/ RICE

SEAFOOD BROTH

TOMATO

VEGETABLE

CREAM OF MUSHROOM

CHICKEN NOODLE SOUP

CREAM OF CHICKEN

ONION DIP AND SOUP MIX (DRY)

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* 10. PLEASE CHOOSE UP TO 10 DRY GOODS

RICE

FLOUR TORTILLAS (2)

SPAGHETTI NOODLES

MACARONI AND CHEESE (2)

CHEESEBURGER HELPER

MISC FLAVORED RICE OR PASTA PACKETS

MASHED POTATOES

ELBOW NOODLES

GRANOLA

OATMEAL

CEREAL (2)

LASAGNA HELPER

ALMOND & WALNUT BLEND

SEASONED SUNFLOWER SEEDS

Old El Paso MEXICAN STYLE SHEET PAN STARTER

Old El Paso ZINGY SOUTHWEST SHEET PAN STARTER

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* 11. PLEASE CHOOSE 1 DRINK

TEA BAGS

DECAF COFFEE

APPLE JUICE

GROUND COFFEE - available after May 7

JUICE BOXES

None of the above

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* 12. PLEASE CHOOSE UP TO 12 CHOICES

TOMATO/SPAGHETTI SAUCE (2 jars or 1 large)

DICED TOMATOES/CRUSHED TOMATOES

WALNUTS

CANNED PASTA (Like Chef Boyardee) (2 cans)

RAMEN NOODLES

RAISINS

PEANUT BUTTER (2 jars or 1 large)

GRANOLA BARS

JELLY

ASSORTED SWEETS- MAY INCLUDE ONE OF PUDDING, CAKE OR BROWNIE MIX

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

PANCAKE SYRUP

ENCHILADA SAUCE MILD

PIZZA DOUGH

PIZZA SAUCE

MANWICH SLOPPY JOE SAUCE

BEEF GRAVY

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* 13. PLEASE CHOOSE YOUR DAIRY OPTIONS

EGGS (2 dozen)

CHEDDAR CHEESE

MILK

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* 14. PLEASE CHOOSE 2 MEATS

HOT DOGS (2)

HAM

PORK CHOPS (2)

GROUND BEEF (2)

TURKEY BACON

FISH STICKS

ROCK FISH

2 lb SHRIMP - after 4/29

CHICKEN THIGHS (2)

CHICKEN LEG QUARTERS

PORK LOIN

CHICKEN BREAST

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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 hace 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 2 TYPES OF CANNED VEGETABLES

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* 7. PLEASE CHOOSE UP TO 3 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 10 DRY GOODS

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* 11. PLEASE CHOOSE 1 DRINK

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* 12. PLEASE CHOOSE UP TO 12 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!