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CEB FRC Food Market Appointment Request Form
Please complete this form to request an appointments for the CEB Family Food Market through the FRC. Once you have completed the form, please utilize the scheduling link to book your appointment directly on our Google Calendar. If you may have any question feel free to contact Angel Nieves @ 302.660.4800 ext. 250. If you are unable to attend your scheduled appt. please notify me at your earliest convenience.
!!! PLEASE BE ADVISED THIS IS A NEW FORM... YOU MUST CLICK THE LINK AFTER YOU SUMBIT TO SELECT A DATE AND TIME !!!
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* Indicates required question
Email
*
Your email
First and Last Name
*
Your answer
Primary Phone Number
*
Your answer
Have you utilized the Food Market previously?
*
Choose
Yes
No
Race/Ethnicity
*
White/ Caucasian
Black/ African American
Hispanic
American Indian/ Alaskan Native
Asian American
Native Hawaiian/ Pacific Islander
Other:
What School/Community Partner are you associated with?
*
Kuumba Academy
Great Oaks
High Roads
University Of Delaware
Network Connect
Other:
Required
If associated with a partner school please provide child's name:
Your answer
Total of household members (adults)?
*
Your answer
Total of children in household
*
Your answer
What is your monthly total household income?
*
Your answer
What is your zip code?
*
Choose
19801
19802
19803
19804
19805
19809
19703
19720
19713
Other
Can we contact you with more information?
*
Yes
No
Maybe
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