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Food Pantry Appointment Form
Please call 401.865.6437 for any questions.
Name
*
First Name/Nombre
Last Name/Apellido
Allergies to food/ Alergias a los alimentos ?
*
Yes/Si
No
What foods are you Allergic too? / A cuales Alimenos eres Alergico?
*
Milk/ Leche
Eggs/ Huevos
Peanuts/ Mantequilla de Mani
Tree nuts/ Nueces de Arbol
Soy/ Soya
Wheat/ Trigo
Sesame/ Anjojoli
Shellfish/ Crustáceos
Fish/ Pescado
None/ Ninguno
Other/ Otro
To better support your household, please indicate any foods you need to limit or avoid:/ Para apoyar mejor a su hogar, por favor indique los alimentos que necesita limitar o evitar:
Foods high in sugar /Alimentos altos en azúcar
Foods high in salt / Alimentos altos en sal
Foods high in fat / Alimentos altos en grasa
Red or processed meats / Carnes rojas o procesadas
Dairy products / Productos lácteos
Other/ Otro
Phone Number
*
Format: (000) 000-0000.
Email
*
example@example.com
Number of Household Member/ Cuantos Miembreo viven en el hogar
*
Number of children (0-17) at home/Número de niños (0-17) en casa
*
Number of adults (18-54) at home/Número de adultos (18-54) en casa
*
Number of seniors (55+) at home/Número de personas mayores (55+) en casa
*
Available Products (Upon availability)
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next
( X )
Green Beans/Cut - Canned
No Salt Added
$
Free
Sweet Peas - Canned
No Salt Added
$
Free
Diced Carrots- Canned
$
Free
TEFAP Garbanzo Beans - Canned
$
Free
TEFAP Dry Cranberries - Bagged
$
Free
White Corn Meal - Bagged
$
Free
Beans Pinto- Bagged
$
Free
Infamil Gentlease
$
Free
Jamine Rice - Bagged
$
Free
TEFAP Dry Chick Peas/ Garbanzo
$
Free
TEFAP 1% Milk
$
Free
TEFAP Dry Black Beans - Bagged
$
Free
Dry Mac & Cheese - Boxed
$
Free
Creamy Peanut Butter
$
Free
Chicken Tuna - Bagged
$
Free
Pasta Spaghetti - Bagged
$
Free
TEFAP Fish - Frozen
$
Free
Comments/ Comentarios
*
Submit
FTC Event Voucher
Yes
Date of last APPT
-
Month
-
Day
Year
Date
Checked inAppointment
Yes
No
STATUS
RED FLAG
Should be Empty: