SOUTH SHORE BACKPACKERS — Student Food Access Program

Family Interest Indicator

We want to hear from you! South Shore Backpackers is exploring a food access program designed to provide nutritious food and support to students and their families. If your family may be interested in receiving food, please complete this short form. Your responses are confidential and will only be used to help us understand community interest and plan the program.
Student’s Name
School Name
Student’s Grade

Other
Do you have additional children who attend Cohasset Public Schools?
If 'Yes', please list the name, grade and school of each additional child below & indicate which school you would like your food delivered to for pickup:
Total number of children in the household
Total number of adults in the household (18 years of age & older)
Does anyone in your household have a food allergy?
If yes, please list ALL food allergies:
Are there any other dietary needs or food restrictions we should be aware of?
What is the most convenient way to receive the food?
Would you prefer a one-time pick-up or a recurring pick-up?
Should be Empty:

Family Interest Indicator