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Request FREE Food Package

This form must be received on or before Monday 5 p.m. for pick up on Thursday between 10 a.m. - 3 p.m.

Contact Information
New Recipient Past Recipient First Name
Spouse Name
Last Name
Address
City
State/Zip
Phone
Email
Individual $15 Family $30 How many children living at home?
Ages of Children

Please check boxes next to items below totaling up to your allotted amount. YOU WILL NOT BE ASKED TO PAY FOR THESE ITEMS. THIS IS OUR GIFT TO YOU. (Prices are there solely for you to be able to total the weekly allotment from the Food Bank.)

DRIED GOODS
White Rice (2 lbs) $2.00
Brown Rice (2 lbs) $2.00
Spaghetti (1 lb) $1.50
Pasta $1.50
Oatmeal (16 oz.) $2.00
Dry Cereal - Sweet $2.50
Dry Cereal - Non Sweet $2.50

CANNED GOODS
Dole Canned Pineapple - Sliced (20 0z) $2.00
Dole Canned Pineapple - Diced (20 0z) $2.00
Sliced Peaches $2.00
Tuna Fish (5 oz) $1.00
Canned Corn $1.50
Canned Peas $1.50
Canned Green beans $1.50
Canned Diced Tomatoes $1.50
Tomato Sauce (15oz.) $1.00

CONDIMENTS
Mayonnaise (15 oz.) $3.00
Ketchup (1 lb) $2.00
Salt (26 oz.) $1.00
BAKING GOODS
Vegetable Oil (48 oz.) $3.50
Soy Milk (32 oz.) $3.50
Almond Milk (32 oz.) $3.50
Sugar (1 lb) $1.75
Cake Mix $1.50

MISCELLANEOUS
Tea Biscuits $1.50
Matzah (11 oz.) $4.00
Jam (18 oz.) $4.00
Peanut Butter (16 oz.) $3.00
Applesauce (25 oz.) $3.00
Bread (1.5 pounds) $3.00
Tea Bags $2.50
Coffee (8 Oz.) $5.00

PRODUCE
In addition to the above selected items, each week you will be able to take home a supply of the following produce items:
Potatoes
Onions
Carrots
Apples
Oranges

TOTAL
Total Amount $
Do you have any other needs that are of emergency nature?

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