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. First and Last 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. PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES. ONLY 1 CAN OF EACH VARIETY. PEAS CORN GREEN BEANS BEANS (Canned) - May be kidney, pinto or black beans PEAS AND CARROTS SLICED POTATOES SWEET POTATOES/YAMS MIXED VEGETABLES CARROTS Question Title * 6. PLEASE CHOOSE 1 DRINK DECAF COFFEE JUICE BOXES K CUPS GROUND COFFEE None of the above Question Title * 7. PLEASE CHOOSE 1 CANNED MEAT SALMON TUNA CHICKEN PORK None of the above Question Title * 8. PLEASE CHOOSE UP TO 2 CANNED FRUIT APPLESAUCE PEACHES PEARS APRICOT MIXED FRUITS NONE Question Title * 9. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP CHICKEN NOODLE CHICKEN AND RICE CREAM OF MUSHROOM TOMATO VEGETABLE BROTH None of the above Question Title * 10. PLEASE CHOOSE UP TO 10 items HAMBURGER HELPER GRANOLA BARS MACARONI AND CHEESE PEANUT BUTTER RAMEN NOODLES FRUIT & NUT MIX RICE SPAGHETTI NOODLES TOMATO/SPAGHETTI SAUCE CEREAL OATMEAL MISC CONDIMENTS - May include one of the following: SPICE MIXES, SALAD DRESSING, KETCHUP, MUSTARD, OIL CANNED PASTA BAGGED COMPLETE MEAL KIT (Various soup/stew type kits) PUDDING or JELLO MIX PANCAKE MIX PANCAKE SYRUP STUFFING MIX DESSERT MIX Question Title * 11. PLEASE CHOOSE YOUR 1 DAIRY OPTION - AS AVAILABLE MILK CHEESE EGGS NONE Question Title * 12. PLEASE CHOOSE 1 MEAT HOT DOGS BACON GROUND BEEF HAM STEAKS FISH FILLETS FISH STICKS CHICKEN Question Title * 13. +FREEZER CHOICE - CHOOSE 1 CORN PIZZA CRUSTS PIZZA MIXED VEGETABLES PEACHES FRENCH FRIES None of the above Question Title * 14. DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS Question Title * 15. 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 * 16. 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 * 17. 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 * 18. We will offer fresh produce if we have it. Please choose your preferences below: SWEET POTATOES ORANGES APPLES POTATOES ONIONS Carrots Done