Eastside Food Pantry Order Form

The Eastside Food Pantry is located at Calvary Church, 995 E. 8th Street and open on Monday and Wednesday from 10-11:30am, and Friday from 3-4:30pm. To quicken the process, please fill out this form before coming. Orders MUST be submitted by 8:30AM for M/W pickup, and by 2:30PM for Friday pickup. Anyone needing emergency food assistance is welcome.
Household Information
 
 
 
 
 
Please select one option.
Please select one option.
Please select one option.
Please select one option.
Pickup Information
The food pantry is open Mondays and Wednesdays, 10-11:30 and Fridays, 3-4:30. Choose a timeframe when you will come to CALVARY CHURCH (995 E. 8TH STREET) to pick up your order. 
Please select one option.
 
Food Pantry Items (Please choose up to 12 items TOTAL, including meat and personal care items)
*Please note that some items may not be available on the day you order them as our inventory is always changing. 
Please select all that apply.
Please select all that apply.
Please select all that apply.
Comments
Use this space to give any extra information for us so that we have your order ready to go for you!
 
 
 
 
Eligibility Verification Information
This table shows a gross income for each household size, based on 2020 Federal Poverty Income Guidelines.


Please read the statement below carefully and then complete requested information check the digital signature box.
Please select all that apply.
USDA Non-Discrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, officers, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint or discrimination, complete the USDA Program Discrimination Complaint Form, (AD 3027) found online at https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632 - 9992.

Submit your completed form or letter to USDA by: 1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave SW, Washington, D.C. 20250 - 9410; 2) fax: (202) 690 - 7442; 3) email: program.intake@usda.gov . 

This institution is an equal opportunity provider.

Description

The Eastside Food Pantry is located at Calvary Church, 995 E. 8th Street and open on Monday and Wednesday from 10-11:30am, and Friday from 3-4:30pm. To quicken the process, please fill out this form before coming. Orders MUST be submitted by 8:30AM for M/W pickup, and by 2:30PM for Friday pickup. Anyone needing emergency food assistance is welcome.