November1125FDR

November 15th Food Distribution Registration
Per the MidSouth Food Bank guidelines: We can only serve three households per car. You will no longer be allowed to pick up for more than three households in one vehicle. Effective June 10, 2024. Thank you.
Preregistration deadline: Wednesday, November 12th

One form per household.

Pickup Saturday, November 15th 9-10am at Journey Church 3719 Shelby Rd Millington TN 38053
Head of household*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Gender*
Age*
Race*
Are you a veteran?*
Name of person picking up the food*

First NameLast Name
List each person in your household*
Total number of children in your household (17 and under)*
Total number of adults in your household (18-59)*
Total number of seniors in your household (60 and over)*
Total household income*
Do you receive this income weekly, monthly, or yearly)*
Email (this will be used for you to confirm that the form has been submitted)*
example@example.com
I certify that the information and income listed is true and correct, that I received food assistance, and that no other member of my household has applied for and received food during this distribution. I understand that misrepresentation of need, or sale, or exchange of food is prohibited.*

Clear
Should be Empty:

November 15th Food Distribution Registration