Millennia Market: Schedule Appointment

Millennia Market

Please complete the form to schedule your appointment and write “N/A” for any items that do not apply to you.
Name*

First NameLast Name
Phone Number*
Email*
example@example.com
Zip Code*
Number of CHILDREN (Age 17 and Under) Living in the Home
Please list the ages of all children*
IF IT DOESN'T APPLY, TYPE NA
How did you hear about us? *
Organization, School, Doctor, etc.
*THE FOLLOWING QUESTIONS ARE FOR

STATISTICS AND RESOURCES

PURPOSES*
Number of ADULTS (Age 18 and Older) Living in the Home*
Do you have any children living in your home?*

YesNo
Do you need diapers?*

YesNo
What size diaper do you need?

123456
How many children do you have?*
Please list the ages of your children*
What school district are they enrolled in?*
What school do they attend?*
Are your children enrolled in the Everett School District?*
Race/Ethnicity*

African AmericanAsianCaucasianHispanicNative AmericanPacific IslanderOther
Which school do they attend?
LIST FOOD ALLERGIES*
IF NO FOOD ALLERGIES, TYPE NA
Do you have a place to prepare hot meals?

YesNoMicrowave Only
Check ALL the items your family can use.

We'll match your choices with what’s available.
Breakfast Items

CerealPancake mixPeanut ButterShelf Stable MilkOatmeal Pack
Cooking Staples and Sauces

Diced TomatoesNoodlesStuffingTomato SauceVegetable OilWhite Rice
Beans and Legumes

Blackeye PeasChickpeas CannedChickpeas DryLentils CannedLentils DryNavy Beans DryPinto Beans DrySplit Peas DryWhite Beans Dry
Canned Meat and Protein

ChickenSalmonTuna
Soups and Quick Meals

Flavored RiceHamburger HelperInstant PotatoesMac & CheeseRamenSoupTuna Helper
Vegetables

CornCranberry SauceFresh PotatoesFresh OnionGreen BeansSpinachSweet Peas
Fruit

ApplesauceCanned FruitDried CherriesFresh Apples
Snacks

Cake MixChipsCookiesCrackersFruit SnacksGranola BarsPecansPopcorn
Frozen Items

ChickenFish NuggetsFish SticksMisc. ItemPorkWhole Turkey
Frozen Fruit
Other Items

Toddler Pink Slippers (size 9)
What day and time would work for you? Please arrive on time and let us know your name and the time of your appointment when you check in. *
Should be Empty: