Please complete the form below to get started with our Home Delivery program:
High Risk
*
I am a high-risk person. (High-risk for these purposes is defined as someone who is 60 years or older OR is a person with a disability OR has a condition/circumstance that qualifies them as high risk.)
I have barriers to accessing my local food pantries (Barriers to accessing food pantries include limited transportation, limited mobility, limited childcare, prohibitive work schedule, or other barriers)
Delivery Frequency
*
I would like a one-time delivery
I would like a recurring delivery - Every other week
I would like a recurring delivery - Once a month
Contact Information
First Name
*
Last Name
*
Street Address 1
*
Apartment/Unit # (If applicable)
City
*
Zip Code
*
State - Home delivery is available to residents of Pierce County, WA only.
*
Washington
Phone Number
*
This phone number is a
Cell phone
Landline
Email
We utilize email to send delivery reminders, we will not send you emails that do not pertain to your deliveries.
Age(s) of people in household
Please enter the number of people in your household that are in the age range listed.
0-2
19-54
65+
3-18
55-64
Demographic Information
Please enter the number of people in your household that identify for each option listed below.
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Biracial/Multiracial
Black/African American
Native American/Alaska Native
White
Other
Household income level: Click
here
to view the income eligibility guidelines.
*
Yes, I meet the income eligibility as defined in the link provided.
No, I do not meet the income eligibility as defined in the link provided.
You do not have to quality for the income eligibility in order to receive home delivery.
Dietary Restrictions
Diabetic/Low Sugar
Limited/No Refrigeration
Soft Diet/Dental Concerns
Please understand that at this time we use the same food boxes for all of our recipients and cannot accommodate specific requests. We are gathering data on dietary considerations to determine the future needs of this program. Check all the boxes that apply to you or any members of your household.
Email
Submit