Order Form

Name *

First

Last

Number of People in Household *

Phone *

Date You Plan to PICK-UP Order or Receive Delivery *

Do you need your order delivered? *

no
yes

Please record your address if you need your order delivered *

Address Line 1

City

State

Enter any dietary restrictions you may have

VOLUNTEER TAKE NOTICE

Select the produce you would like

Canned Pasta, select the number of cans you would like

Canned Pork , select the number of cans you would like

Canned Beef , select the number of cans you would like

Baked Beans, select the number of cans you would like

Select the cereal you would prefer

We have many brands of cereal. If you have a favorite, list it and we will try to accomodate your preference.

---------------------------------------------CANNED VEGETABLES---------------------------------------Select the number of each can you would like; 1-3 people-up to 3 cans, 4 people or more-up to 7 cans

peas

green beans

corn

mixed vegetables

Spinach

Yams

Assorted Beans: Select the number of cans you would like (1-3 people-2 cans) (4 and up- 3 cans)

Check the Beans you would prefer

Black Beans
Kidney Beans
Garbanzo Beans

Soups, list the type of soup(s) you would like in the box below (e.g., chicken noodle, broth, ramen noodles, etc.)

-------------------------------------------------CANNED FRUIT-------------------------------------------Select the number of each can you would like; 1-3 people-up to 2 cans, 4 people or more-up to 3 cans

Peaches

Fruit Cocktail

Pears

Figs

Dried Plums

Dates

Would you like White Rice?

Yes
No

Would you like Brown Rice?

Yes
No

Select the number of Canned Tuna you would like (1-3 people-2 cans) (4 and up- up to 4 cans)

Select the number of Salmon you would like (1-3 people-2 cans) (4 and up- up to 4 cans)

Enter the type of condiments you would like in the box below (e.g., salad dressing, mustard, barbecue sauce, etc.)

Select the items you would like

Select 2 out of the 4 items below or none

Tomato Sauce, select the number of cans/jars you would like, (1-3 people-up to 2 cans) (4 and up- up to 4 cans)

Crushed/Diced Tomato, select the number of cans/jars you would like, (1-3 people-up to 2 cans) (4 and up- up to 4 cans)

Enter the type of personal item(s) you would like in the box below (e.g., deodorant, tooth paste, soap etc.)

Select the items you would like

Enter the type of drink(s) you would like in the box below (e.g., water, juice, flavored water, ice tea etc.)

Nutritional Drinks

We provide nutritional drinks to clients: struggling to maintain a healthy weight or trying to manage blood sugar.

If you are struggling to maintain a healthy weight due to:

loss of appetite
cancer
swallowing problems
recovery from recent surgery

Then select Regular in the box below.

If you are a diabetic or are struggling to manage blood sugar and a healthy weight., then select the Glucose control drink in the box below.

We provide 4 drinks per households. If more than one resident needs theses drinks, specify the number of each type needed.

(Often doctors or nutritionist have recommended that these drinks be used by our clients. The Food Pantry reserves the right to ask for medical proof from a doctor before dispensing these drinks.)

Select the type of Nutritional drink needed and the quantity. 4 per household.

Regular (Ensure, Boost Red Label)

Glucose Control Drink (Glucerna, Boost Blue Label)

Enter the type of bread and pastry you would like.

------------------------------------------------Meat/Poultry/Fish-------------------------------------------------------------------------------(1-3 people-up to 3) (4 people or more - up to 5)---------------------------------------------------------------------Select by choice-----------------------------------------

Pork Chops

Lamb

Veal

Beef

Steak

Pork Loins 4-5 lbs.

Whiting Filet(2 lbs.)

Meatless Ground Beef

Small Packages of Poultry

Split Chicken Breast (5 lb.)

Ham, 3lb.

Select the dairy/frozen items you would like

Check the appropriate box if you need diapers for a member of the household.

Baby Diapers
Adult Diapers

Enter the diaper size and gender for the baby *

Enter the diaper size and gender for the adult *

Do you need Baby Food? (if yes, please plan to come in and select)

Yes
No

Are there any item(s) that were not listed and you might want.

Yes
No

Enter any item(s) that were not listed and you might want.

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