CHOICE FOOD PANTRY COMMUNITY REACH INC FOOD PANTRY FOOD CHOICES Question Title * 1. PLEASE PROVIDE THE FOLLOWING INFORMATION 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 WHOLE CORN KERNALS GREEN BEANS PEAS BEANS - May be kidney, pinto or garbonzo YAMS/SWEET POTATOES LARGE CUT MIXED VEGETABLES SLICED WHITE POTATOES Question Title * 6. PLEASE CHOOSE UP TO 1 CANNED FRUIT APPLESAUCE FRUIT COCKTAIL MANDARIN ORANGES PEACH CUPS Question Title * 7. PLEASE CHOOSE 1 CAN of MEAT TUNA CHICKEN SALMON Question Title * 8. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP CHICKEN BROTH CHICKEN NOODLE TOMATO VEGETABLE BEEF STEW CREAM OF MUSHROOM CHICKEN RICE BROCCOLI & CHEESE LOADED POTATO Other (please specify) Question Title * 9. PLEASE CHOOSE UP TO 5 DRY GOODS RICE INSTANT POTATOES (1) MISC SIDE DISHES - MAY INCLUDE RICE, PASTA OR POTATOES SPAGHETTI NOODLES LASAGNA HELPER CHEESEBURGER HELPER BEEF STROGANOFF BEEF PASTA TUNA HELPER ELBOW MACARONI TACO SHELLS Question Title * 10. PLEASE CHOOSE 1 DRINK TEA BAGS K CUPS GROUND COFFEE DECAF GROUND COFFE APPLE JUICE JUICE BOXES (4 boxes) ORANGE JUICE None of the above Question Title * 11. PLEASE CHOOSE UP TO 8 CHOICES TOMATO/SPAGHETTI SAUCE DICED TOMATOES/CRUSHED TOMATOES JELLY WALNUTS ALMONDS HAZLENUTS PECAN CHIPS GRANOLA BARS CHEF BOYARDE SWEET HEAT RUB (TWIST'D Q) ENCHILADA SAUCE PANCAKE MIX MISC CONDIMENTS - May include one of the following: MAYO, SALAD DRESSING, KETCHUP, MUSTARD CEREAL GRANOLA OATMEAL Question Title * 12. PLEASE CHOOSE YOUR 2 DAIRY OPTIONS . EGGS VEGETABLE OIL SPREAD CHEESE Question Title * 13. PLEASE CHOOSE 1 FREEZER ITEM BROCCOLI LEAN CUISINE SPAGHETTI STEAMFRESH CORN,CARROTS & ASPARAGUS PEAS BLUEBERRIES POTATO SKINS NONE None of the above Question Title * 14. PLEASE CHOOSE 3 MEATS GROUND BEEF GROUND TURKEY CHICKEN BREAST CHICKEN DRUMSTICKS SAUSAGE CHICKEN THIGHS HOT DOGS CHICKEN GIZZARDS ASSORTED CUT OF BEEF - 1 pack ASSORTED CUTS OF PORK - 1 pack PULLED PORK TURKEY SAUSAGE CRUMBLES Question Title * 15. DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS Question Title * 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 No Question Title * 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 No Question Title * 18. DOES ANYONE IN YOUR HOUSEHOLD HAVE A BIRTHDAY THIS MONTH? IF SO, PLEASE LIST THEIR NAME AND DOB. Question Title * 19. Do you have school aged children at home - ages 5-15? If so we will include a bag of extra snacks during the summer months while supplies last. Yes No Done