Contact-Free Food Delivery
PLEASE READ THE FOLLOWING:
Contact-Free Deliveries are for those that have mobility disabilities, seniors (60 and older), and those most at-risk during COVID-19.
If you do not qualify for this program, please visit our website at
for other methods of receiving food through Share Food Program.
*This form is to be filled out for each delivery date you would like to receive a delivery.
** This program is limited to only serving those located within the City of Philadelphia.
*** There will be one (1) box distributed to each household.
This program is Volunteer-based. We cannot guarantee your delivery, but if unable to deliver, please see our website to see a pantry near you. Please visit
Sign in to Google
to save your progress.
First and Last Name
Home Address (Street number and name only)
Apartment Number/ Unit
What is your household size?
Number of children ( 17 and under) in household:
Number of adults (ages 18-59) in household:
Number of seniors (ages 60 and up) in household:
What is your annual/yearly income?
$0 - $19,140
$32,581 - $39,300
$39,301 - 46,020
$46,021 - $52,740
$52,741 - $59,460
$59,461 - $66,180
$66,181 or more
Date of Delivery *You MUST signup for each delivery date using a new form each time. WE ARE NOW ON A WAITLIST . THESE DATES ARE NOT GUARANTEED FOR DELIVERY.
Friday, July 23 (Waitlist)
Saturday, August 28 (Waitlist)
If you are filling out this form on behalf of an individual, please type your name below
If you are filling out this form on behalf of an individual and you are apart of an organization, please type your organization's name below
USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at
, and at any USDA office, or wrote a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866)632-9993. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture (2) fax: (202) 690-7442
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW (3) email:
Washington, D.C. 20250-9410
The institution is an equal opportunity provider.
Please read and agree to ALL the statements below to receive your box of food:
I or a representative on my behalf, understand that making a false statement may result in my having to pay for the value of the food improperly issued to me and may subject me to criminal prosecution under state and federal law
I or a representative on my behalf, understand by filling out this information, I consent to being contacted by a Share Food Program volunteer and/or staff member to verify any given information
I or a representative on my behalf, understand by filling out this information, I may be contacted by any third parties that are associated with the "Home-Delivery Program".
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google.
Terms of Service