Bob Box - Distribution Tracking Form
Thank you for helping us in the fight to eliminate Senior Hunger in Kansas! Please use this form to report for each Bob Box you have distributed.

<em>If you complete this form, and you receive a confirmation page, you do not need to mail in the Bob Box Distribution Tracking Card</em>

<b>Note:</b> Compelling stories about the impact of the program are <b>critical</b> to our ability to continue to raise funds for and support the program, and we thank you for your time in telling them to us.

<b>Questions / Help:</b> (316) 265-FOOD
<em> If you have questions about the Bob Box program, please contact Debi Kreutzman.</em>
<em> If you need help completing this form, please contact Patrick Hutchison.</em>

You can find this form online at: www.kansasfoodbank.org/bobboxform

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Reporting Agency Information
Agency *
Click the drop down arrow and select your agency from the list! If your agency is not listed, please call us BEFORE completing your report so we can update the form.
Name *
Please enter YOUR name (the name of the person submitting this report online) so if we have any questions we can get in touch with you.
Date *
Enter the date you distributed the Bob Box
MM
/
DD
/
YYYY
Notes
(optional) Any special notes about this client or stories you would like to share about the impact of the Bob Box on this household. Remember: clients should remain anonymous. Compelling stories about the impact of the program are critical to our ability to continue to raise funds for and support the program, and we thank you for your time in telling them to us.
Client Household Information
Note: If there were no household members in one of the age groups below, please enter '0'.
Number of Seniors (65 years and older) *
Include both male & female in this category who are 65 years and older.
Number of Adults, Not Seniors *
This is the total number of adults, ages 18 to 64.
Number of Children *
This is the total number of children ages birth to 17.
ZIP Code *
What is the ZIP Code where the household is located?
New Client *
To the best of your knowledge, is this the first time the client has received a Bob Box?
Finish & Submit
Click the Submit button below and wait for the confirmation page. Once the form has submitted, you will be taken to a new page that says 'Thank you'. If you left a required question blank, the form will not submit and the blank question will be outlined in an orange box. Complete the question, and submit again. If you have any trouble, please give us a call!
OFFICE USE ONLY
Check this box if the form was entered by Food Bank staff.
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