Food Pantry Request Form

Food Pantry Request Form

Please select the items that your household is currently in need of. We will do our best to meet your requests depending on our inventory. Please note food allergies, dietary restrictions and special circumstances at the end of the form. If you have not visited our pantry before you will need to complete an intake over the phone before we are able to assist you.
Name *

First Name Last Name
Date of Birth *

Month/Day Year
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
How many in your home? *

Adults Children
Please Choose from the following list of inventory.

Choose 1 for most important and 3 for least important. If you do not need an item at all you do not need to rank it. Please note that we are not able to offer one of everything to every client, you will need to choose what is most needed today for your family.

Pasta & Pasta Sauce

	1	2	3

1 is Not as Important, 3 is Really Important

Macaroni & Cheese

	1	2	3

1 is Not as Important, 3 is Really Important

Peanut Butter & Jelly

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Chicken

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Tuna

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Chili with out without beans

	1	2	3

1 is Not as Important, 3 is Really Important

Rice a Roni

	1	2	3

1 is Not as Important, 3 is Really Important

Condensed Soups

	1	2	3

1 is Not as Important, 3 is Really Important

Cream of Soups (cream of chicken, cream of mushroom, etc)

	1	2	3

1 is Not as Important, 3 is Really Important

Ramen Noodles

	1	2	3

1 is Not as Important, 3 is Really Important

Chunky Soup or Stews

	1	2	3

1 is Not as Important, 3 is Really Important

Instant Mashed Potatoes

	1	2	3

1 is Not as Important, 3 is Really Important

Crispy Skillet Potatoes

	1	2	3

1 is Not as Important, 3 is Really Important

Hamburger Helper

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Green Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Peas

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Potatoes

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Sauerkraut

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Spinach

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Mixed Vegetables

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Corn

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Cream Corn

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Chickpeas

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Refriend Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Kidney Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Canned White Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Black Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Canned White Beans

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Yams

	1	2	3

1 is Not as Important, 3 is Really Important

Canned Mixed Fruit

	1	2	3

1 is Not as Important, 3 is Really Important

Canned fruit pie mix (apple or pumpkin)

	1	2	3

1 is Not as Important, 3 is Really Important

Flour

	1	2	3

1 is Not as Important, 3 is Really Important

Sugar

	1	2	3

1 is Not as Important, 3 is Really Important

Salt

	1	2	3

1 is Not as Important, 3 is Really Important

Yeast

	1	2	3

1 is Not as Important, 3 is Really Important

Dried Rice, Beans, Lentils, Peas

	1	2	3

1 is Not as Important, 3 is Really Important

Breakfast & Snack Items

Please rank these items in the same way, 1 for most important and 3 for least important.

Breakfast Cereal

	1	2	3

1 is Not as Important, 3 is Really Important

Breakfast Cereal - Farina/Cream of Wheat

	1	2	3

1 is Not as Important, 3 is Really Important

Breakfast Cereal - Oatmeal

	1	2	3

1 is Not as Important, 3 is Really Important

Pancake Syrup (we do not have pancake mix at this time)

	1	2	3

1 is Not as Important, 3 is Really Important

Breakfast Bars

	1	2	3

1 is Not as Important, 3 is Really Important

Granola Bars

	1	2	3

1 is Not as Important, 3 is Really Important

Condensed Milk

	1	2	3

1 is Not as Important, 3 is Really Important

Shelf Stable Milk

	1	2	3

1 is Not as Important, 3 is Really Important

Sweetened Condensed Milk

	1	2	3

1 is Not as Important, 3 is Really Important

Protein Powder

	1	2	3

1 is Not as Important, 3 is Really Important

Nutritional Drinks (Ensure, Muscle Milk)

	1	2	3

1 is Not as Important, 3 is Really Important

Nutritional Drinks (Ensure, Muscle Milk)

	1	2	3

1 is Not as Important, 3 is Really Important

Cake Mix & Frosting

	1	2	3

1 is Not as Important, 3 is Really Important

Jello

	1	2	3

1 is Not as Important, 3 is Really Important

Almond Flour

	1	2	3

1 is Not as Important, 3 is Really Important

Sugar Substitute (such as Splenda)

	1	2	3

1 is Not as Important, 3 is Really Important

Crackers

	1	2	3

1 is Not as Important, 3 is Really Important

Chips/Pretzels

	1	2	3

1 is Not as Important, 3 is Really Important

Cookies/Sweets

	1	2	3

1 is Not as Important, 3 is Really Important

Condiments (Ketchup, Mustard)

	1	2	3

1 is Not as Important, 3 is Really Important

KCups

	1	2	3

1 is Not as Important, 3 is Really Important

Perishable Items

Please rank these items in the same way, 1 for most important and 3 for least important.

Frozen Hamburger

	1	2	3

1 is Not as Important, 3 is Really Important

Frozen Hotdogs

	1	2	3

1 is Not as Important, 3 is Really Important

Frozen Fish/Seafood

	1	2	3

1 is Not as Important, 3 is Really Important

Frozen Chicken

	1	2	3

1 is Not as Important, 3 is Really Important

Dozen Eggs

	1	2	3

1 is Not as Important, 3 is Really Important

Loaves of Bread

	1	2	3

1 is Not as Important, 3 is Really Important

Breakfast/Dessert donation from D&W

	1	2	3

1 is Not as Important, 3 is Really Important

Cake from D&W Bakery

	1	2	3

1 is Not as Important, 3 is Really Important

Toiletries/Household Goods

Please rank these items in the same way, 1 for most important and 3 for least important.

Toilet Paper

	1	2	3

1 is Not as Important, 3 is Really Important

Paper Towel/Napkins

	1	2	3

1 is Not as Important, 3 is Really Important

Shampoo

	1	2	3

1 is Not as Important, 3 is Really Important

Bar Soap

	1	2	3

1 is Not as Important, 3 is Really Important

Handsoap

	1	2	3

1 is Not as Important, 3 is Really Important

Bodywash

	1	2	3

1 is Not as Important, 3 is Really Important

Toothpaste

	1	2	3

1 is Not as Important, 3 is Really Important

Toothbrushes

	1	2	3

1 is Not as Important, 3 is Really Important

Hair Brush

	1	2	3

1 is Not as Important, 3 is Really Important

Combs

	1	2	3

1 is Not as Important, 3 is Really Important

Deodorant

	1	2	3

1 is Not as Important, 3 is Really Important

Dish Soap

	1	2	3

1 is Not as Important, 3 is Really Important

Laundry Soap

	1	2	3

1 is Not as Important, 3 is Really Important

Almost Done!
Please list food allergies or special circumstances here
Please Select a Date & Time to Pick Up Your Food *
By typing my full name in this box I am certifying that all of the above is true to the best of my knowledge. I understand that fraudulent answers or mis-use of the pantry may result in The Grand Haven Salvation Army not being able to help my family in the future. *

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