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CHOICE FOOD PANTRY
COMMUNITY REACH INC FOOD PANTRY FOOD CHOICES
*
1.
PLEASE PROVIDE THE FOLLOWING INFORMATION. PLEASE DO NOT COMPLETE MORE THAN 2 WEEKS PRIOR TO APPOINTMENT.
PLEASE BE SURE TO LIST A FIRST AND LAST NAME!
(Required.)
First and Last Name
Address
City/Town
State/Province
ZIP/Postal Code
Email Address
Phone Number
*
2.
WHICH SCHOOL DISTRICT DO YOU RESIDE IN?
(Required.)
RED LION
DALLASTOWN
EASTERN YORK
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3.
HOW MANY PEOPLE RESIDE IN YOUR HOUSEHOLD?
(Required.)
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)
5.
PLEASE CHOOSE 2 TYPES OF CANNED VEGETABLES 2 CANS OF EACH VARIETY
PEAS
CORN
GREEN BEANS
BEANS (Canned) - May be kidney, pinto or black beans
MIXED VEGETABLES
CARROTS
SPINACH
6.
PLEASE CHOOSE 1 DRINK
DECAF COFFEE
JUICE
K CUPS
GROUND COFFEE
SHELF STABLE MILK
None of the above
7.
PLEASE CHOOSE 1 CANNED MEAT
SALMON
TUNA
PORK
CHICKEN
None of the above
8.
PLEASE CHOOSE UP TO 2 CANNED FRUIT
APPLESAUCE
PEARS
APRICOT
MIXED FRUITS
PEACHES
NONE
9.
PLEASE CHOOSE UP TO 2 DIFFERENT CANS OF SOUP
CHICKEN NOODLE
CHICKEN AND RICE
CHICKEN TORTILLA
CREAM OF CHICKEN
TOMATO
VEGETABLE
BROTH
None of the above
10.
PLEASE CHOOSE UP TO 10 items
MASHED POTATOES
GRANOLA BARS
MACARONI AND CHEESE
COOKING OIL
BEEF STEW
TUNA HELPER
HAMBURGER HELPER
FRUIT & NUT MIX
PISTACHIOS
RICE
SPAGHETTI NOODLES
TOMATO/SPAGHETTI SAUCE
CEREAL
OATMEAL
MISC CONDIMENTS - May include one of the following: SPICE MIXES, SALAD DRESSING, KETCHUP, MUSTARD, OIL
BAGGED COMPLETE MEAL KIT (Various soup/stew type kits)
MUFFIN MIX
*
11.
PLEASE CHOOSE YOUR 1 DAIRY OPTION - AS AVAILABLE
(Required.)
CHEESE
EGGS
MILK
NONE
*
12.
PLEASE CHOOSE 1 MEAT
(Required.)
FISH STICKS
GROUND BEEF
3LB HAM
TILAPIA FILLETS
HOT DOGS
CHICKEN
13.
+FREEZER CHOICE - CHOOSE 1
BRUSSEL SPROUTS
PIZZA
CORN ON THE COB
CALIFORNIA BLEND
GREEN BEANS
None of the above
14.
DO YOU OR ANYONE IN YOUR HOUSEHOLD HAVE ANY ALLERGIES? IF SO, PLEASE PROVIDE DETAILS
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
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
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!