BASIC ESSENTIALS ORDER FORM

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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.

TODAY'S DATE *

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) *

number of people who want TOOTHPASTE *

number of people who want SOAP *

number of people who want LAUNDRY DETERGENT *

number of people who want SHAMPOO *

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