MCUM Grocery Order Form

MCUM Food Pantry Order Form
Welcome to MCUM!

**Please note: delivery orders are capped at 20 deliveries every Tuesday and Friday and are first-come, first-served basis.**

We now offer online pantry services so that you can make your choices from the safety, comfort, and convenience of your home and pick them up quickly during business hours.

We also offer delivery service on Tuesdays & Fridays. All requested delivery orders from 12:00am Thursday - 11:59pm Sunday will be delivered on Tuesdays. All orders from 12:00am Monday - 11:59pm Wednesday will be delivered on Fridays.

How it works:
- Fill out the order form below. If this is your first time using MCUM's services since August, you will need to complete the CDBG questions. These questions do not impact your eligibility for services, we just need them for federal grants.
- Once we receive your order, we will put your grocery sacks together. We will do our best to match your preferences to the items we currently have available.
- We will contact you via email or phone to when your order is ready for pickup. Please make sure you leave your contact information for us.
- If you're picking up, come to 827 West 14th Court, Bloomington, IN 47404 (next to Tri North Middle School) to pick up your order during business hours. (Monday, Tuesday, Thursday - 9 AM- 3:30 PM; Wednesday 9 AM - 3 PM)
- All orders must be picked up within 2 business days.
Thank you for choosing MCUM for your grocery needs.
Shopper Information
Name *

First Name Last Name
Your Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
How many people live in your household? *
Max of 6 people; Must match number in MCUM's client database, if returning family.
Please type first & last name(s) of all individuals in the home and their birthdays (MM/DD/YYYY). *
Is this your first time using MCUM's pantry since August 1, 2020? (If so, you will be prompted to complete annual data for grant funding - this is NOT an eligibility determination, but questionnaire required for MCUM to receive federal funding.) *

Yes No
Your full name
Your adress
Today's date
I am a female head of household – adult female with dependents and no male significant other:

Yes No
I consider myself to be Hispanic:

Yes No
I consider myself to be (check one):

White Black/African American Asian American Indian/Alaskan Native Native Hawaiian/Other Pacific Islander American Indian/Alaskan Native & White Asian & White Black/African American & White American Indian/Alaskan Native & Black/African American Other/Multi-racial
My household size is:
Our total household income is:
Please enter your household's annual income
By typing/signing here, I acknowledge the information above is true.

Clear
Preferred contact method when order is ready (make sure your info listed above is accurate): *

Email Phone call
How do you want to get your groceries? *

I will pick them up. Please deliver it to the address above. I have read the above instructions and understand my order will be delivered on a Tuesday or Friday.
Fruits & Vegetables
I would like vegetables in my order. *

Yes No
Please select the type(s) of vegetables your family would enjoy:

green beans corn potatoes carrots mixed vegetables sweet potatoes/yams peas
Are there any vegetables your family will NOT eat? Please list them.
If we have fresh vegetables available, would you like to add some to your order?

Yes No
I would like canned fruit in my order *

Yes No
Some of our favorite fruits are (choose all that apply)

Peaches Pineapple Fruit cocktail Pears Oranges Applesauce
Are there any fruits your family will NOT eat? Please list them.
If we have fresh fruit available, would you like to add some to your order?

Yes No
What kind of canned tomato products would you like? *

Diced Tomatoes Crushed Tomatoes Whole Tomatoes Pasta sauce Tomato paste Any None
Protein
What kind of beans would you prefer *
Would you like peanut butter? *

Yes No
If you would like peanut butter, do you prefer creamy or crunchy?

Creamy Crunchy
Would you like meat? *

Yes No
Please select the type of meat your family would enjoy:

Tuna Chicken Salmon Beef Pork Spam
If you had to choose one over the other, would you prefer canned or frozen meat?

Canned Frozen No meat at all, please
Starches
Which of the following option(s) would your family prefer: *

Helper Meal Pasta Side Potato Side Rice Side Stuffing None
Would you prefer pasta or rice *

Pasta Rice Neither
Would you like ramen noodles? *

Yes - chicken Yes - beef Yes - doesn't matter the flavor no
Would you like crackers? *

Yes No
What kinds of cereal do you like? *
If we have bread available, would you like some?

Yes No
Would you like baking mix? *

Yes No
Would you like macaroni & cheese? *

Yes No
Soup
Please choose from all the soups your family would enjoy. *

Mushroom Broccoli Chicken noodle Tomato Stew Clam chowder Vegetable Vegetable beef Chicken & vegetable Chef boyardee Ravioli Chili
Miscellaneous
Are there any infants in your home? *

Yes No
Would you prefer salty or sweet snacks? *
Would you like a sample kit of small hygiene items? *NOT full size; please come in for full size cleaning & hygiene items.
Other notes for us:
If you can think of anything else you would like us to know as we prepare your groceries, please type it in the box.
Should be Empty:

MCUM Food Pantry Order Form

Shopper Information

Fruits & Vegetables

Protein

Starches

Soup

Miscellaneous