Food Pantry Pick-Up Request Form (New Client)

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For best results use the Google Chrome Web Browser when completing this form.At this time masks are now optional for those who are fully vaccinated. Based on CDC Guidelines, we strongly recommend that those who have not been vaccinated wear masks.
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Are You a New Client of the Food Pantry?Choose YES if you have have never been to the Table of Hope Food Pantry before. Choose NO if you have a Food Pantry Card and are an existing client.
YESNO
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You should be a new client (NOT have a Pantry Card) of the Table of Hope Food Pantry to use this form. If you have used our services complete the Food Pantry Pick-Up Request Form (Existing Client).
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Some Things to Remember

1. Contents of food boxes may vary each week depending availability. There is no guarantee, but we will do our best to include meat and other proteins whenever possible.

2. Clients may receive up to two boxes per month. We will be tracking when you last received a box using your assigned pantry card number.

3. An order form must be filled out each time you request a box.

4. Presently (5/1/20) we are distributing food boxes on Tuesdays from 9:00 a.m. to 12:00 p.m. and from 1:00 p.m. to 4:00 p.m. at our 156 S. Kansas location in Wichita, Kansas. Online appointments must be made at least two hours in advance. If you need food and cannot come before 4:00 pm on Tuesday call (316) 267-1852 and press option 2 to speak to a volunteer.
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How It Works

1. Complete and submit this form. You must complete this order form each time you come back.

2. Each week we review these forms and create a schedule. We will ONLY call you back if there is an issue.

3. On your scheduled pick-up day/time enter the alley behind the church (off of English street). Please approach the alley facing West (Toward Hydraulic). This means you must come from Minneapolis street. A volunteer will ask your name.

If you are driving, do not get out of your car.

If you are on foot or riding a bike, remain along the fence.

4. Once you have been checked in:

If you are driving head, down the alley and unlock your car door or trunk.

If you are on foot or riding a bike, sit on the steps in front of the red side door.

5. A volunteer will either load your food into your vehicle or bring it to you on the steps.
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Name (Primary)* This field is required.Enter the first and last name of the primary (household) Table of Hope Food Pantry card holder.
First Name
Last Name
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Date of Birth (Primary)* This field is required.Enter the birth date (MM-DD-YYYY) of the Primary Household Client.
Date
Month
Day
Year
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Drivers Licence or ID Number* This field is required.
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Photo Identification Required (Primary)* This field is required.Upload a picture of a State Driver's License, State ID, National ID, Passport, or Consulate ID
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Address (Primary)* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Proof of Address Required (Primary)* This field is required.Upload a picture of a Utility Bill or any other piece of mail sent directly to one of the household members at the primary address.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Phone Number (Primary)* This field is required.Enter the phone number of the primary (household) Table of Hope Food Pantry card holder. This is the number we will use to contact you if there are any issues with your application or pick-up date and time.
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Additional Phone Number (Primary)You have the option of providing us with an additional phone number should we have any issue with your order.
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Email (Primary)Enter the email of the primary (household) Table of Hope Food Pantry card holder. We will use this to contact you if we cannot reach you by phone.
A confirmation email will be sent to this address
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Preferred Language (Primary)* This field is required.
English
Spanish
Vietnamese
Other
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Ethnicity (Primary)* This field is required.
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Other or Mixed
for grant writing purposes
17
Gender (Primary)* This field is required.
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Total Number of People in Household* This field is required.Enter the number of people in your household. Be sure to include yourself.
Including yourself
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Total Number of People in Household (Old Form)
Including yourself
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Next you will be asked to enter the following information for all other members of your household.

Name

Date of Birth

Gender

Ethnicity

Relationship to you
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You will also be asked to provide identification (an ID) for each member of your household listed on your application.

For those 18 years and older you must attach a picture of a PHOTO ID (State Driver's License, State ID, National ID, Passport, Consulate ID)

For those 17 years older or younger you may attach a picture of a NON-PHOTO ID (Insurance Card, Birth Certificate, Shot Record, Social Security Card)
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Name (Other in Household 1)
First Name
Last Name
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Date of Birth (Other in Household 1)
Date
Month
Day
Year
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Photo ID (Other in Household 1)Upload a picture of a Photo ID for this person in your household. This can be a State Driver's License, State ID, National ID, Passport, Consulate ID, etc.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 1)Upload a Non-Photo ID for this person in your household.This can be a Medical Card, a Birth Certificate, a Shot Record, a Social Security Card.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 1)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
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Gender (Other in Household 1)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 1)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 2)
First Name
Last Name
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Date of Birth (Other in Household 2)
Date
Month
Day
Year
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Photo ID (Other in Household 2)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 2)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 2)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
34
Gender (Other in Household 2)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
35
Relationship to Applicant (Other in Household 2)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 3)
First Name
Last Name
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Date of Birth (Other in Household 3)
Date
Month
Day
Year
38
Photo ID (Other in Household 3)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 3)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 3)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
41
Gender (Other in Household 3)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 3)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 4)
First Name
Last Name
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Date of Birth (Other in Household 4)
Date
Month
Day
Year
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Photo ID (Other in Household 4)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 4)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 4)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
48
Gender (Other in Household 4)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 4)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 5)
First Name
Last Name
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Date of Birth (Other in Household 5)
Date
Month
Day
Year
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Photo ID (Other in Household 5)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 5)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 5)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
55
Gender (Other in Household 5)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 5)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 6)
First Name
Last Name
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Date of Birth (Other in Household 6)
Date
Month
Day
Year
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Photo ID (Other in Household 6)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 6)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 6)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
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Gender (Other In Household 6)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 6)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 7)
First Name
Last Name
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Date of Birth (Other in Household 7)
Date
Month
Day
Year
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Photo ID (Other in Household 7)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 7)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 7)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
69
Gender (Other in Household 7)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 7)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Name (Other in Household 8)
First Name
Last Name
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Date of Birth (Other in Household 8)
Date
Month
Day
Year
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Photo ID (Other in Household 8)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Non-Photo ID (Other in Household 8)
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
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Ethnicity (Other in Household 8)
Asian
African American or Black
Caucasian or White
Native American or American Indian
Native Hawaiian or Pacific Islander
Latino or Hispanic
Other or Mixed
for grant writing purposes
76
Gender (other in Household 8)
Male
Female
Transgender Male (F to M)
Transgender Female (M to F)
Other
Choose not to disclose
for grant writing purposes
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Relationship to Applicant (Other in Household 8)
Enter the relationship of this person to you (son, daughter, cousin, etc.).
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Dogs/Cats? (optional)We are able to provide one small bag of dog food, and/or cat food and cat litter per household per visit (based on availability). Check the appropriate box(es) below. If you don't have any pets, click next to move to the next screen.
Dog Food
Cat Food
Cat Litter
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In addition to providing food for people we are also able to provide a limited amount of dry pet food for dogs and cats. If you need pet food please complete the fields below.
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Number of Dogs in Household (optional)Enter the number of dogs in the household. We are able to provide one small bag of dry dog food per household.
1
2
3
4
5
We are able to provide one small bag of dog food per household.
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Number of Cats in Household (optional)Enter the number of cats in the household. We are able to provide one small bag of dry cat food per household.
1
2
3
4
5
We are able to provide up to five small bags of dry cat food per household.
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If Cats in Household (optional) do you need litter?If you have cats in your household, indicate if you need cat litter.
Yes
No
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ATTENTION!!!!

On the next screen you will select an apointment time. CHECK THE DATE CAREFULLY!

ONLY AVAILABLE TIMES ARE LISTED. IF ALL SLOTS ARE FULL THE SELECTION CALENDAR WILL AUTOMATICALLY MOVE TO THE NEXT WEEK (YOU COULD BE MAKING AN APPOINTMENT FOR THE FOLLOWING WEEK BY MISTAKE).

Choose a different time, schedule for another week or call (316) 267-1852 to speak with a scheduling volunteer.

We may close early or change appointment availability at our discretion - this is why appointments are so important! We always do our best to make times available for you. Food pantry volunteers stand and work outside to serve you so weather has a big impact on our ability to operate. Extremely hot or cold days or other inclement weather events will likely result in reduced appointment availability.
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Appointment* This field is required.Choose an appointment time, You have a 30-minute window to pick-up your food (for example if you select 1:00 pm you will have from 1:00-1:30 pm to pick up your order).Online appointments must be made at least two hours in advance. ONLY AVAILABLE TIMES ARE LISTED BELOW. If a time does not appear, this means all slots in that time frame are full. Choose a different time, schedule for another week or call (316) 267-1852 to speak with a scheduling volunteer.
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Picking up for or with someone else?If you are going to be picking up for or with someone else, please provide the First and Last Name(s) of that(those) individuals so we can have all of your orders ready to go together when you arrive. Note that a separate online order must be completed for each household picking up food.
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We have everything we needWe will NOT call to confirm your appointment unless there is an issue with your order. Please arrive within 30 minutes of the time you selected. If for any reason you need to cancel your appointment call us at (316) 267-1852 and speak with a volunteer or leave us a message. CHECK THE EMAIL ACCOUNT YOU ENTERED ABOVE FOR A CONFIRMATION MESSAGE. THIS WILL LET YOU KNOW YOUR REQUEST WENT THROUGH. THIS FORM WORKS BEST WITH GOOGLE CHROME.
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Appointment Type
Call In
Walk-In
Walk-Up
Online
Missing Online Appt
Volunteer
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Scheduled By:
Helen
Judie
Other: __________
Duplicate (Not Scheduled)
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Tags
Todo
In Progress
Done
Should be Empty: