OutREACH Questionnaire

OutREACH Questionnaire
Parent/Guardian Name

First NameLast Name
Scholar's Name

First NameLast Name
What is the best way to contact you?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Household size
Number of adults
Number of children
Do you currently have access to the following? Check all that apply:
Please list any dietary restrictions in your household. If there are none, please write “N/A”
Please list any food allergies in your household. If there are none, please write “N/A”
Requests*

*Please note that we cannot guarantee that the items selected will be available.
Please select the food items that you and your household would like:

Other
Please select the household items that you and your household would like:

Other
Should be Empty:

Requests*