Food Pantry Family Intake Form / Despensa de Alimentos Formulario de Consumo Familiar

Cornerstone Church Mobile Food Pantry. We bring groceries to your home every other week on Tuesdays. No pick up available on site. Serving the Bluffton/Hilton Head area. Please fill out this form and click submit.

Despensa móvil de Alimentos, Iglesia Cornerstone. Nosotros hacemos la entrega a domicilio los Martes de cada dos semana. No hay disponibilidad de recoger los alimentos. Por favor llene el formulario.

Date / Fecha

Name / Nombre

Address / Dirección

Neighborhood Name if applicable

Phone / Teléfono

School children attend / A qué escuela asisten

Please select all that apply.

Bluffton Elem. Bluffton High Bluffton Middle HE McCracken Middle M.C. Riley Elem. May River High Okatie Elem. Pritchardville Elem. Red Cedar Elem. River Ridge HHI Early Childhood Center HHI High HHI IB Elem. HHHI Middle HHI School for the Creative Arts Not Applicable

Household Info / Información Familiar

Preferred Language / Idioma

Please select one option.

English Spanish

# of People / # de Personas en total

# of Adults / # de Adultos

# of Children / # de niños

Ages of the Children / edad de los niños

Dietary Restrictions / Restricciones Dietéticas

Food allergies / Alergias a alimentos

Please select one option.

yes/si no

If yes, type / Si dijo sí-explique

Lactose-intolerant / Intolerancia a la lactosa

Please select one option.

yes/si no

Vegetarian / Vegetariano

Please select one option.

yes/si no

Are allergies for the whole family or will you still accept these items?

Need baby food (no formula) / Necesita comida para bebé (no fórmula)

Please select one option.

yes/si no

Family delivery Tuesday Afternoons

Account # (to be completed by Cornerstone Church)

Notes: (to be completed by Cornerstone Church)

Food Pantry Family Intake Form / Despensa de Alimentos Formulario de Consumo Familiar

Description

Please Fix the Following