You must submit this order before 6:00 PM the day before the day you plan to pick up the order. Fill out the entire form as accurately as possible. When completed, click on the submit button at the bottom. The Food Pantry serves individuals and families in the Fort Atkinson School District. Fields marked with * are required. Select the Size of Your Household * 1 Person 2 to 3 Persons 4 to 5 Persons 6 or more Persons Where You Live City of Residence * Your Street Address * Required if you request delivery. Our Hours OPEN Monday and Thursday – 3:00 PM until 5:30 PMCLOSED Tuesday, Wednesday, Friday, Saturday, and Sunday Pick Up or Delivery * I Will Pick Up My Order Request Delivery Delivery ONLY on Monday and Thursday mornings from 10:30 to 11:30. Deliveries are made for people who are homebound or otherwise unable to come into the food pantry during serving hours. Day of Pick Up * Choose a day… Time you plan to arrive * Choose a time… Your Contact Information Full Name * Email Address * Phone Number * Have you received food from the Fort Atkinson Food Pantry before? * YES NO Are you at least 18 years old? * YES NO Please understand that the variety of food at our pantry changes often and at times we may substitute with similar items. Soup Limit 0 Total 0 Over the limit Cream Soup − + Chicken Soup − + Vegetable Soup − + Tomato Soup − + Potato Limit 0 Total 0 Over the limit Hamburger Helper − + Boxed Potato − + Canned Potato − + Fresh Potatoes − + Canned Fruit Limit 0 Total 0 Over the limit Applesauce − + Mixed Fruit − + Pears − + Peaches − + Other if Available − + Specify Other Fruit Canned Vegetables Limit 0 Total 0 Over the limit Green Beans − + Corn − + Peas − + Baked Beans − + Black Beans − + Carrots − + Kidney Beans − + Tomato Product − + Mixed Vegetables − + Wax Beans − + Other if Available − + Specify Other Vegetable Cereal Limit 0 Total 0 Over the limit Cheerios − + Corn Flakes − + Oats n Honey − + Oatmeal − + Sweet Cereal − + Rice Crispies − + Other if Available − + Specify Other Cereal Peanut Butter Limit 0 Total 0 Over the limit Peanut Butter − + Canned Pasta / Chili Limit 0 Total 0 Over the limit Canned Pasta − + Canned Chili − + Spaghetti Limit 0 Total 0 Over the limit Spaghetti − + Add Spaghetti Sauce? No Sauce Yes Add Sauce Canned Tuna / Chicken Limit 0 Total 0 Over the limit Canned Tuna − + Canned Chicken − + Macaroni & Cheese Limit 0 Total 0 Over the limit Macaroni & Cheese − + Pancake Mix Limit 0 Total 0 Over the limit Pancake Mix − + Pasta / Rice Limit 0 Total 0 Over the limit Pasta (1 pound) − + Rice (1 pound) − + Hamburger / Ground Turkey Limit 0 Total 0 Over the limit Subject to Availability and Size of Household Hamburger − + You will not receive more hamburger than shown for your household size. Ground Turkey − + Margarine Limit 0 Total 0 Over the limit Subject to Availability and Size of Household Margarine − + Bread Limit 0 Total 0 Over the limit White Bread − + Wheat Bread − + Hotdogs Limit 0 Total 0 Over the limit Package of Hotdogs − + Cheese Limit 0 Total 0 Over the limit Package of Cheese − + Eggs Limit 0 Total 0 Over the limit Dozen Eggs − + Milk Limit 0 Total 0 Over the limit 1/2 Gallon of Milk − + Misc. Meat Subject to Availability and Size of Household. Select the meat you would like to receive. Chicken Breasts Pork Roast Whole Chicken Fish Filets Chicken Thighs Anything Else? Request Additional Items Special Dietary Needs or Food Allergies I verify that I have read the Fort Atkinson Food Pantry Privacy Policy * Leave this empty Submit Order 0 Review & Submit
