Please Register If you Plan to Pick up From the Supplemental Mobile Pantry on Monday, April 6th
This is SEPARATE from the breakfast / lunch distribution the school district is doing. This distribution is for families, elderly & residents in the Clermont Northeastern area. Please fill out ONE per family. If you are filling out for an elderly neighbor/relative please ensure you fill out a separate form for them. This will be DRIVE-UP style. Stay in your car & we will bring to you.
Full Name *
Your answer
If someone is picking up on your behalf, please enter his/her name here
Your answer
Full Mailing Address *
Your answer
Elderly *
Number of Adults in Household *
Number of Children in Household *
Preferred Pickup Location (select only one) *
If you are homebound due to medical issues or elderly (high risk) and do not have someone who can pick up for you, please ensure your email or phone # is entered in the next step. This is will be a drive-up style pickup, no getting out of your car, volunteers will bring out to your car.
Email or Phone # *
Please enter your EMAIL if you would like to be notified of changes and or pickup times/locations.
Your answer
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