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. FREEZER CHOICE - CHOOSE 1 DICED ONIONS CORN SWEET POTATOES GREEN BEANS PEAS PEPPER AND ONION MIX STRAWBERRY CUPS BREAKFAST HAM EGG CHEESE SANDWICH BROCCOLI NONE Question Title * 6. PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES WHOLE CORN KERNALS GREEN BEANS PEAS BEANS - May be kidney, pinto or garbonzo SLICED POTATOES SPINACH Question Title * 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT APPLESAUCE MIXED FRUIT PEACHES PEARS NONE Question Title * 8. PLEASE CHOOSE 1 CAN of MEAT CHICKEN SALMON BEEF PORK TUNA NONE Question Title * 9. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP BROTH - CHICKEN OR BEEF CHICKEN W/ RICE SEAFOOD BROTH TOMATO VEGETABLE CLAM CHOWDER CREAM OF MUSHROOM CHICKEN NOODLE SOUP ONION DIP AND SOUP MIX (DRY) CREAM OF CHICKEN Question Title * 10. PLEASE CHOOSE UP TO 6 DRY GOODS RICE FLOUR TORTILLAS MISC FLAVORED RICE OR PASTA PACKETS MACARONI AND CHEESE LASAGNA HELPER CHEESEBURGER HELPER MASHED POTATOES ALMONDS ELBOW NOODLES SPAGHETTI NOODLES GRANOLA OATMEAL ALMOND & WALNUT BLEND SEASONED SUNFLOWER SEEDS Question Title * 11. PLEASE CHOOSE 1 DRINK TEA BAGS APPLE JUICE DECAF GROUND COFFEE GROUND COFFEE K CUPS None of the above Question Title * 12. PLEASE CHOOSE UP TO 8 CHOICES TOMATO/SPAGHETTI SAUCE DICED TOMATOES/CRUSHED TOMATOES ENCHILADA SAUCE MILD BEEF GRAVY CANNED PASTA (Like Chef Boyardee) RAMEN NOODLES RAISINS PEANUT BUTTER GRANOLA BARS PANCAKE SYRUP PANCAKE MIX ASSORTED SWEETS- MAY INCLUDE ONE OF PUDDING, CAKE OR BROWNIE MIX MISC CONDIMENTS - May include one of the following: MAYO, SALAD DRESSING, KETCHUP, MUSTARD MANWICH SLOPPY JOE SAUCE CEREAL PIZZA SAUCE PIZZA DOUGH MIX Question Title * 13. PLEASE CHOOSE YOUR 2 DAIRY OPTIONS . EGGS CHEDDAR CHEESE MOZZARELLA CHEESE MILK Question Title * 14. PLEASE CHOOSE 2 MEATS HOT DOGS HAM PORK CHOPS GROUND BEEF GROUND TURKEY TURKEY BACON ROCKFISH FILLETS CHICKEN THIGHS CHICKEN LEG QUARTERS FISH STICKS TILAPIA FILLETS CHICKEN BREAST PORK LOIN SHRIMP 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 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 * 19. Do you have any school aged children, ages 5 -17? If yes, we will include an extra bag of easy to prepare foods and snacks for the summer months of June, July and August. You will receive during your regular pantry monthly appointment. Yes No Done