New Customer Registration Form

Blessed Hands Outreach

3690 Hwy 90 E., Crestview FL 32539

ian@projecthoperc.net

www.facebook.com/blessedhandscrestview

Text RSVP to Ian @ (346) 405-1299
Household Registration Form
Full Name

First NameLast Name
Address

Street Address (not required)

Street Address Line 2 (not required)

City (required)State / Province (required)

Postal / Zip Code (required)
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
How did you hear about us?
How many Ethnicities in your home? (not required but helpful for us)
How many in your home?
What age groups do you provide meals/snacks for? (click all that apply)
Are there any food allergies/dietary restrictions/religious restrictions?:
Suggestions if any for further improvement:
Distribution begins at 3:30 and runs until 5:30pm. Please text (346-405-1299) or fill out this form each week if you intend to come so that we may prepare a box for you!
Should be Empty:

Distribution begins at 3:30 and runs until 5:30pm. Please text (346-405-1299) or fill out this form each week if you intend to come so that we may prepare a box for you!