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 BROCCOLI VEGAN, MEATLESS OPTIONS FRENCH FRIES FROZEN PEACHES CORN SWEET POTATO FRIES STRAWBERRIES 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 MIXED VEGETABLES Question Title * 7. PLEASE CHOOSE UP TO 2 CANNED FRUIT APPLESAUCE MIXED FRUIT PEACHES APRICOTS PEARS NONE Question Title * 8. PLEASE CHOOSE 1 CAN of MEAT PORK 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 TOMATO VEGETABLE BEEF STEW CHICKEN NOODLE SOUP ONION DIP AND SOUP MIX (DRY) CHILI STEAK HOUSE STYLE CREAM OF CHICKEN CREAM OF MUSHROOM Question Title * 10. PLEASE CHOOSE UP TO 6 DRY GOODS RICE MISC DRIED PASTA HAMBURGER HELPER MACARONI AND CHEESE CEREAL MUFFIN/BREAD MIX SPAGHETTI NOODLES OATMEAL SCALLOPED POTATOES PANCAKE MIX MASHED POTATOES Question Title * 11. PLEASE CHOOSE 1 DRINK GROUND COFFEE KCUPS JUICE - BOTTLED JUICE BOXES DECAF COFFEE NONE SHELF STABLE MILK None of the above Question Title * 12. PLEASE CHOOSE UP TO 6 CHOICES TOMATO/SPAGHETTI SAUCE SOFT TACO KIT PISTACHIOS DICED TOMATOES/CRUSHED TOMATOES TORTILLA POCKET KITS STUFFING MIX PECANS CHEF BOYARDEE PEANUT BUTTER GRANOLA BARS HAZLENUTS ASSORTED SWEETS- MAY INCLUDE ONE OF PUDDING, CAKE OR BROWNIE MIX MISC CONDIMENTS - May include one of the following: SPICE MIX, SALAD DRESSING, KETCHUP, MUSTARD BETTY CROCKER HAM & CHEESE POTATO SCRAMBLERS PIZZA SAUCE SALSA Question Title * 13. PLEASE CHOOSE YOUR DAIRY OPTIONS. MILK CHEESE Question Title * 14. PLEASE CHOOSE 2 MEATS HOT DOGS HAM STEAKS PORK CHOPS GROUND BEEF GROUND TURKEY SAUSAGE FISH STICKS CHICKEN FISH FILLETS 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