Seniors Form for Grocery Delivery
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What is your name?
What is your address (including apartment number if you live in one)?
What is your phone number?
What groceries do you need?
Do you have any preferences or requirements (e.g. organic/allergies/preferred store)?
When do you need this by?
When are you available to receive the delivery (please provide specific times/dates)?
Privacy Agreement: I, the undersigned, do hereby allow the members of the Teens Helping Seniors organization to use the information enclosed within this Google Form (including my name, address, phone number, and other identifying contact information) to fulfill contactless supply delivery to me. I give full permission to Teens Helping Seniors to provide this information to organization volunteers, if necessary. Further, I waive all rights to legal action or recourse against the members of Teens Helping Seniors in regards to the usage of my identifying contact information for the purpose of contactless supply delivery to me. By signing this document, I hereby affirm that I have read and agree to the Teens Helping Seniors User Privacy Policy to be found at *
Please type your signature below. *
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