Clone of October1026FDR

November 14th Food Distribution Registration
Reminder: You must bring an ID showing the correct address you registered with or mail with your address.
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 11th

One form per household.

Pickup Saturday, November 14th 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.Format: (000) 000-0000.
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
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.
Should be Empty:

November 14th Food Distribution Registration

Reminder: You must bring an ID showing the correct address you registered with or mail with your address.

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.