Food Bank Selection Form

Please use this form for food bank selections. We will do our best to fulfill the requested items, however not all selections maybe available. Thank you, LEKT Food Bank Team

Date

First Name*

Last Name*

Address*

Contact Information - REQUIRED*

Phone Number is REQUIRED for follow up questions and scheduling for the food bank coordinator.

Phone

Is this your first time at the food bank since July 2023?*

Select

Do you know if you have completed the Annual EFAP Form?*

Select

Please Complete the Annual Intake Form with the Food Bank Coordinator

Is your household currently on Quarantine/Isolation?*

Select

I am requested food bank delivery.

This is ONLY available for Tribal Elders, disabled individual and those with NO transportation available in the LEKT Community.

Select

How many children ages 0-2 are living in your home?*

Select

How many children ages 3-18 are living in your home?*

Select

How many household members ages 19-54 are living in your home?*

Select

How many household members ages 55+ are living in your home?*

Select

Do you have a sensitivity to dairy products?*

Select

Do you have any allergies?

Select

Please list allergeies

Do you have a place to store cold/frozen foods?*

Select

Would you like hygiene products?*

We will do our best to include requested items, based on availability.

Select

Hygiene choices

Select