Free meals and groceries program registration

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Your answers to these questions are absolutely CONFIDENTIAL, and can only be accessed by our staff. We will take them into account in order to finalize our delivery schedule. We may not always be able to achieve your preferred choices.

What is your HelpBerkeley username (if you don't remember, write: don't remember)? *

What is your primary phone number? *

I worry that my food will run out this month before I have money to buy more. *

Often true

Sometimes true

Never true

The food I buy just doesn’t last, and I don’t have money to get more this month. *

Often true

Sometimes true

Never true

I am unable to pick up cooked food or groceries in person at an outdoor food pantry, such as Berkeley Food Network, because... *

Next Section: Groceries and Meals Request

The number of meals we are producing is still limited. Your total number of weeks per month for meals and grocery requests together can be up to 6: if you need more, please contact us. Also, please note that at this time we cannot honor dietary preferences.

In the coming month, for how many persons in your household, including you, should we deliver free meals and/or groceries? *

1 person

2 persons

3 persons

4 persons

You represent that you will be home for delivery, and that you will store the food in the fridge immediately upon delivery. We count on your (or someone's) presence at delivery. You is fully responsible for food safety if not present at delivery. *

I will be present at delivery. If I don't reply to the driver, I assume full responsibility for food safety

Required

Every Monday, between 3:30pm and 5:30pm, we may be able to deliver free groceries (2 medium to large bags), or free meals (6 meals). In the coming month, how many weeks would you like a grocery or a meal delivery? IMPORTANT: AT THIS TIME WE ARE UNABLE TO INCREASE OUR MEAL DELIVERIES *

0 weeks

1 week of groceries

2 weeks of groceries

4 weeks of groceries

Other:

If we are unable to deliver your meals in a given week because of limited capacity, should we deliver groceries instead? *

Yes

Other:

If you have a medical or specific need for meals (for instance, because you are unable to cook), please share this with us here. We will use this information to establish a priority for those who need meals.

Please indicate your dietary preferences below (these preferences only apply to meals: groceries are not included).

I prefer vegetarian meals

I prefer no red meat

I prefer no pork

Please enter any comment you wish to add here

Thank you!

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