Exit CHOICE FOOD PANTRY COMMUNITY REACH INC FOOD PANTRY FOOD CHOICES Question Title * 1. PLEASE PROVIDE THE FOLLOWING INFORMATION. PLEASE DO NOT COMPLETE MORE THAN 2 WEEKS PRIOR TO APPOINTMENT. Name Address City/Town State/Province ZIP/Postal Code Email Address Phone Number Question Title * 2. WHICH SCHOOL DISTRICT DO YOU RESIDE IN? RED LION DALLASTOWN EASTERN YORK Question Title * 3. HOW MANY PEOPLE RESIDE IN YOUR HOUSEHOLD? Question Title * 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) Question Title * 5. +FREEZER CHOICE - CHOOSE 1 PEACH CUPS (2) ROASTED RED POTATOES & GREEN BEANS CORN FRENCH FRIES ASPARAGUS STRAWBERRIES CHICKEN ENCHILADAS SKILLET MEAL - ORANGE CHICKEN SKILLET MEAL - SAUSAGE AND PEPPERS Question Title * 6. PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES WHOLE CORN KERNALS GREEN BEANS PEAS BEANS - May be kidney, pinto or garbonzo PINK BEANS IN CAROLINA STYLE BBQ SAUCE SLICED POTATOES SPINACH MIXED VEGETABLES CARROTS Question Title * 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT APPLESAUCE MIXED FRUIT PEACHES PEARS NONE Question Title * 8. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP BROTH - may be beef or chicken CHILI MAC - BEANS, MACARONI PASTA & MEAT TOMATO VEGETABLE CHICKEN NOODLE SOUP CREAM OF MUSHROOM CREAM OF CHICKEN Question Title * 9. PLEASE CHOOSE UP TO 15 items Fruit and Nut Mix Walnuts PANCAKE MIX CANNED TUNA CANNED CHICKEN TACO SHELLS HAMBURGER HELPER STUFFING MIX PIZZA SAUCE MACARONI AND CHEESE RAMEN NOODLES CHEF BOYARDEE or similiar SLOPPY JOE MIX SPAGHETTI NOODLES SPAGHETTI SAUCE SCALLOPED POTATOES RICE CEREAL OATMEAL GRANOLA BARS PEANUT BUTTER GRAVY MIX OR CANS MISC CONDIMENTS - May include one of the following: SPICE MIXES, SALAD DRESSING, KETCHUP, MUSTARD MISC SWEETS -May include baking items such as chocolate chips, flour , pudding or other items Question Title * 10. PLEASE CHOOSE 1 DRINK GROUND COFFEE DECAF COFFEE KCUPS JUICE - BOTTLED None of the above Question Title * 11. PLEASE CHOOSE YOUR 2 DAIRY OPTIONS. MILK CHEESE EGGS - IF AVAILABLE NONE Question Title * 12. PLEASE CHOOSE 2 MEATS HOT DOGS HAM STEAKS PORK CHOPS GROUND BEEF TURKEY SLICED DELI STYLE PORK LOIN POLLOCK FILLETS CHICKEN QUARTERS FISH STICKS/NUGGETS BREADED FISH Question Title * 13. DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS Question Title * 14. 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 No Question Title * 15. 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 No Question Title * 16. 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! Question Title * 17. We will offer fresh produce if we have it. Please choose your preferences below: Oranges Apples Potatoes Sweet Potatoes Onions Carrots Done