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 FROZEN STRAWBERRY CUPS FROZEN PEACH CUPS CHIMICHANGAS PEPPERONI PIZZA BROCCOLI CORN 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 CARROTS Question Title * 7. PLEASE CHOOSE UP TO 1 CANNED FRUIT APPLESAUCE MIXED FRUIT PEACHES PEARS CRANBERRY SAUCE NONE Question Title * 8. PLEASE CHOOSE 1 CAN of MEAT CHICKEN SALMON BEEF PORK SPAM - as available NONE Question Title * 9. PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP BROTH - CHICKEN OR BEEF CHICKEN W/ RICE TOMATO VEGETABLE CREAM OF MUSHROOM CHICKEN NOODLE SOUP CREAM OF CHICKEN SURPRISE ME :) Question Title * 10. PLEASE CHOOSE UP TO 8 DRY GOODS RICE SPAGHETTI NOODLES MACARONI AND CHEESE CHEESEBURGER HELPER MASHED POTATOES TUNA HELPER STUFFING MIX EGG NOODLES TACO SHELLS CAKE OATMEAL BAKING ITEMS SUCH AS FLOUR,BROWN SUGAR,ETC Question Title * 11. PLEASE CHOOSE 1 DRINK APPLE JUICE GROUND COFFEE DECAF GROUND COFFEE K CUPS - CRAN APPLE JUICE None of the above Question Title * 12. PLEASE CHOOSE UP TO 10 CHOICES TOMATO/SPAGHETTI SAUCE DICED TOMATOES/CRUSHED TOMATOES MICROWAVE POPCORN PISTASHIOS WALNUTS JELLY ALMONDS CANNED PASTA (Like Chef Boyardee) RAMEN NOODLES RAISINS PEANUT BUTTER GRANOLA BARS PUDDING MIX MISC CONDIMENTS - May include one of the following: MAYO, SALAD DRESSING, KETCHUP, MUSTARD PANCAKE SYRUP PANCAKE MIX CEREAL Question Title * 13. PLEASE CHOOSE YOUR 2 DAIRY OPTIONS . (ONLY 1 CHEESE) EGGS CHEDDAR CHEESE AMERICAN CHEESE MILK Question Title * 14. PLEASE CHOOSE 2 MEATS HAM PORK CHOPS SMALL SHRIMP POLLUCK FILLETS CHICKEN DRUMSTICKS WHOLE CHICKEN 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