I HAVE READ THE ABOVE STATEMENT, UNDERSTAND. AND AGREE.

I HAVE READ THE ABOVE STATEMENT DO NOT UNDERSTAND AND NEED MORE INFORMATION.

Name *

First Name

Last Name

Phone

(###)

###

####

What are the ages of your family members? *

0-5

6-12

13-19

Over 20

I understand that my information is confidential and not shared with anyone. I understand that my name will not be disclosed for any reason. I understand that my location, ages and family size information is used for statistic reporting only. *

YES

NO

I understand that these items are not to be sold and if reselling of items is brought to your attention I will automatically be forfeiting my pantry privileges. *

YES

NO

I understand that there is only ONE pick up per family and it is not permitted to send photos from other accounts and if this is brought to your attention I will automatically be forfeiting my pantry privileges. *

YES

NO

I have sent screenshots of items I would like to Momma B's Pantry Facebook page and waiting to be contacted with pick up instructions via Facebook Messenger *

YES

NO