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.
IF YOU ALSO PLACED A CLOTHING ORDER AND WOULD LIKE TO PICK UP BOTH ORDERS AT ONCE, PLEASE WAIT UNTIL YOU ARE CALLED ABOUT YOUR CLOTHING ORDER before swinging by.
* Required
TODAY'S DATE
*
MM
/
DD
/
YYYY
LAST NAME OF HEAD OF HOUSEHOLD
*
Your answer
FIRST NAME OF HEAD OF HOUSEHOLD (if a case manager will be picking up, please also write that name)
*
Your answer
CONTACT NUMBER or EMAIL in case we have questions (if a case manager is the contact, please write that)
*
Your answer
If SOMEONE ELSE will be picking up your order, please write their name below.
Your answer
TOTAL PEOPLE IN THE HOUSEHOLD
*
Your answer
NUMBER OF ADULT MALES (18 years and older)
*
Your answer
NUMBER OF ADULT FEMALES (18 years and older)
*
Your answer
NUMBER OF NON-BINARY ADULTS (18 years and older)
Your answer
NUMBER OF CHILDREN (0 years- 17 years)
*
Your answer
number of people who want TOILET PAPER (DO NOT INCLUDE CHILDREN WHO WEAR DIAPERS)
*
Your answer
number of people who want TOOTHPASTE
*
Your answer
number of people who want SOAP
*
Your answer
number of people who want LAUNDRY DETERGENT
*
Your answer
number of people who want SHAMPOO
*
Your answer
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