Fresh Food Box e-Form

heathersthomson

11 years ago

Please fill the following form out in order to participate in our Fresh Food Box program. Bear in mind that there is one box per household and it must have a Huu-ay-aht citizen residing in the residence. You will see a confirmation message on the screen and receive an email from Kristen Young.

Disclaimer – This program has been set up to help Elders and those with low incomes. If you are not in need please keep this in mind, as this program is subject to the availability of funds provided by Steelhead LNG.

Form:

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Thank you for your response. ✨

Full Name:

Address:

City:

Postal Code:

Phone:

Email:

Delivery city:

How many Huu-ay-aht citizens are in your home?

Do you have any children under age of 18 years old living with you? (required)

Yes

Birth to 5 years old

12 to 18 years old

6 to 11 years old

Main source of income

Do you have any allergies?

If yes, please identify

We will do our best to avoid putting known allergens in a food box and apologize if it happens. Please inform us if it occurs continually.

Cities we deliver to: Anacla, Port Alberni, Nanaimo, Victoria and Vancouver.

Form:

Thank you for your response. ✨

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