Shopping List - Open Cupboard Food Pantry

Client Status of OPEN CUPBOARD *

Current New

Date (Pick up or delivery date) *

Date

Preferred Pick Up Time

Tuesday AM Tuesday PM Wednesday AM Thursday AM Friday PM

Full Name *

First Name Last Name

Contact Number

Area Code Phone Number

E-mail

# Adults (18 + older) *

# Seniors (65 + older) *

# Children (under 18) *

School Lunch Program?

Yes No

How many children are eligible?

Transportation

PICK UP Delivery - INCLUDE ADDRESS (MUST have approval from Main Office) LINK Other

Delivery Address

Please choose the item (s) you would like - UP TO THE TOTAL AMOUNT ALLOWED for your family size.

GRAINS - 1-2 Family Size = 3 choices
3-4 Family Size = 5 choices
5+ Family Size = 6 choices

GRAINS

SOUP - 1-2 Family Size = 3 choices
3-4 Family Size = 5 choices
5+ Family Size = 6 choices

SOUP

MISCELLANEOUS - 1-2 Family Size = 1 choice
4+ Family Size = 2 choices

MISC

VEGETABLES - 1-2 Family Size = 5 choices
3-4 Family Size = 7 choices
5+ Family Size = 8 choices

VEGETABLES

FRUIT- 1-2 Family Size = 2 choices
3-4 Family Size = 3 choices
5+ Family Size = 4 choices

FRUIT

PROTEIN - 1-2 Family Size = 2 choices
3-4 Family Size = 3 choices
5+ Family Size = 4 choices

PROTEIN

NON-FOOD - 1-2 Family Size = 1 choice
3+ Family Size = 2 choices

NON-FOOD

OCFP - Open Cupboard Pantry Clients ONLY

USDA - United States Department of Agriculture

TANF - Temporary Assistnace to Needy Families (Must have children under 18 years old)

SFPP - State Food Purchase Program

Produce (based on availability)

YES NO

Baked Goods (based on availability)

YES NO

Eggs

Yes No

Milk

Yes No

Shelf Milk

Yes No

Cheese TYPE

Meat & Meat Alternatives

YES

NO

Pork

Venison

Beef

Chicken

Meatless /Plant Based

Fish

ADDITIONAL PICKS / OTHER

Use this field to request specialty items such as diapers, pet food, laundry etc.

Pick up Option *

In house appointment requested No contact pick up

My appointment is currently scheduled for: (date/time)