Millennia Market: Schedule Appointment

Name*

First NameLast Name
Phone Number*
Format: (000) 000-0000.
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 STATISTICAL & RESOURCE PURPOSES ONLY
Number of ADULTS (Age 18 and Older) Living in the Home*
YesNo
YesNo
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?*
African AmericanAsianCaucasianHispanicNative AmericanPacific IslanderOther
Which school do they attend?
LIST FOOD ALLERGIES*
IF NO FOOD ALLERGIES, TYPE NA
YesNoMicrowave Only
Check ALL the items your family can use.

We'll match your choices with what’s available.
CerealPancake mixPeanut ButterShelf Stable MilkOatmeal Pack
Diced TomatoesNoodlesStuffingTomato SauceVegetable OilWhite Rice
Black Beans DryBlackeye PeasChickpeas CannedChickpeas DryLentils CannedLentils DryNavy Beans DryPinto Beans DrySplit Peas DryWhite Beans Dry
ChickenTuna
Flavored RiceHamburger HelperInstant PotatoesMac & CheeseRamenSoupTuna Helper
CornFresh PotatoesFresh OnionGreen BeansSpinachSweet Peas
ApplesauceCanned FruitDried CherriesMandarin OrangesPineapple Juice
Cake MixChipsCookiesCrackersFruit SnacksGranola BarsPecansPopcorn
ChickenFish NuggetsFish SticksGround TurkeyMisc. ItemPorkWhole Turkey
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:

THE FOLLOWING QUESTIONS ARE FOR STATISTICAL & RESOURCE PURPOSES ONLY