BASIC ESSENTIALS ORDER FORM
Please fill out one form per household. A household may place an order 1 time each month.

WHEN WILL MY ORDER BE READY?

Orders are packed on Tuesdays and Thursdays.

Orders submitted BEFORE 1 pm on TUESDAYS will be ready for pick-up on that THURSDAY.

Orders submitted BEFORE 1 pm on THURSDAYS will be ready for pick-up on the following TUESDAY.


PICK-UP HOURS are TUESDAYS and THURSDAYS 10am - 2pm. Please pick up your order WITHIN 2 WEEKS ordering. If it is not picked up within that timeframe, it will be UNPACKED.

YOU CAN HAVE SOMEONE ELSE PICK UP YOUR ORDER.  


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TODAY'S DATE *
MM
/
DD
/
YYYY
LAST NAME OF HEAD OF HOUSEHOLD *
FIRST NAME OF HEAD OF HOUSEHOLD    (if a case manager will be picking up, please also write that name) *
CONTACT NUMBER or EMAIL in case we have questions  (if a case manager is the contact, please write that) *
If SOMEONE ELSE will be picking up your order, please write their name below.
TOTAL PEOPLE IN THE HOUSEHOLD *
NUMBER OF ADULT MALES (18 years and older) *
NUMBER OF ADULT FEMALES (18 years and older) *
NUMBER OF NON-BINARY ADULTS (18 years and older)
NUMBER OF CHILDREN (0 years- 17 years) *
number of people who want TOILET PAPER   (DO NOT INCLUDE CHILDREN WHO WEAR DIAPERS) *
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number of people who want TOOTHPASTE *
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number of people who want SOAP *
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number of people who want LAUNDRY DETERGENT *
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number of people who want SHAMPOO *
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