Assistance program Application
Reach and Serve Foundation
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Any additional family member
*
Yes
No
How many additional family member?
1
2
3
4
5
6
7
Please note that delivery services are presently limited to seniors residing in Tottenham and Alliston. For delivery arrangements, kindly contact us at 705-434-5300.
*
Yes, I am Senior who requires grocery delivery.
I will collect the groceries
What type of support do you need?
*
Grocery
Financial assistance
Clothing
Children school backpack
Hygiene products
Could you provide more details on the support you require?
What type of groceries do you need?
Your choice is not guarantee but we will try if it is possible.
How much money do you normally spend on groceries monthly?
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