Exit 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 ONION AND PEPPER BLEND MAC & CHEESE BITES BREADED CHICKEN BITES TURKEY SAUSAGE BOWL BROCCOLI SPANAKOPITA STRAWBERRY TOASTER PASTRIES STRAWBERRY CUPS Question Title * 6. PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES WHOLE CORN KERNALS GREEN BEANS PEAS BEANS - May be kidney, pinto or garbonzo BAKED BEANS SLICED POTATOES SPINACH CARROTS 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 TUNA NONE Question Title * 9. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP BROTH - CHICKEN OR BEEF OR VEGETABLE CHICKEN W/ RICE SEAFOOD BROTH TOMATO VEGETABLE CHICKEN NOODLE SOUP ONION DIP AND SOUP MIX (DRY) CREAM OF CHICKEN Question Title * 10. PLEASE CHOOSE UP TO 6 DRY GOODS RICE CHICKEN HELPER HAMBURGER HELPER TUNA HELPER MACARONI AND CHEESE MASHED POTATOES SPAGHETTI NOODLES OATMEAL SCALLOPED POTATOES TACO SHELLS Question Title * 11. PLEASE CHOOSE 1 DRINK TEA BAGS JUICE DECAF COFFEE GROUND COFFEE K CUPS None of the above Question Title * 12. PLEASE CHOOSE UP TO 6 CHOICES TOMATO/SPAGHETTI SAUCE DICED TOMATOES/CRUSHED TOMATOES SALSA PEANUT BUTTER GRANOLA BARS PANCAKE SYRUP PANCAKE MIX MISC CONDIMENTS - May include one of the following: MAYO, SALAD DRESSING, KETCHUP, MUSTARD CEREAL Question Title * 13. PLEASE CHOOSE YOUR 2 DAIRY OPTIONS . EGGS MILK CHEESE Question Title * 14. PLEASE CHOOSE 2 MEATS HOT DOGS GROUND BEEF CHICKEN DRUMSTICKS SAUSAGE FISH STICKS HAM STEAKS CHICKEN BREAST FROZEN WHOLE TURKEY SALMON 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! Done