RESERVE GROCERY BOX FORM We are now on a 2-Week distribution cycle This reservation is for June 19th pickup Please note the pick up is now at Veg-In-Out Market! The new pick up time is 10 am See your reservation email for details This form can be submitted up to 123 times. Please enter: An email, so we can identify you at pickup Please re-enter your email First name and the initial of your last name A telephone number in case we need to contact you Please confirm that you will be able to PICK UP your box on Saturday afternoon, June 19th at 10am . Note: This service is currently only available by pickup. Yes, I can pick up 10am Enter the number of adults and children you will be feeding 123456789101112+ List any allergens so we can do our best to avoid putting them in your box GlutenPeanutsTree Nuts Answer all the questions below accurately. Please note your responses do not affect your eligibility. This information will help us apply for additional funding to better serve the needs of our community. Are you a SNAP, TANF, Medicaid, SSDI, or SSI Recipient?YesNo Please enter your zip code Employment Status ---Prefer Not to SayDisabledLaid-OffEmployed-Full TimeEmployed-Part TimeRetiredStudentWillfully Unemployed "Important Note! If for any reason you are no longer able to pick up, please be sure to let us know as soon as possible so that we can give the box to the next household on our wait list. Please send an email to firstname.lastname@example.org"