NCC Pantry Shopper Information Form for Newmarket and Newfields NH Residents

If you live in Newmarket or Newfields NH, please complete this form so that we can best serve you through the Newmarket Community Church Food Pantry.
The information collected here is for statistical purposes only and allows NCC to access more food for less in our efforts to better serve you.  Your contact information will not be shared beyond NCC.
 
 
Please select all that apply.
Please select one option.
Please select one option.
Contact Information
 
 
 
 
 
Household Information
Please answer each question in this section, even if your answer is 0. For example, if you have 2 people living in your home who are between 19-59 years of age, then you would put a 2 for that answer and a 0 in the other age categories.
 
 
 
 
 
Please select all that apply.
Emergency Contact Information
In the event that you are at the pantry and have an emergency of any sort, who shall we contact on your behalf to inform them of your situation?
 
 
Program and Income Information
Please select all that apply.
Please select all that apply.

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the NCC Pantry is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), disability, age, or reprisal or retaliation for prior civil rights activity.

Please select all that apply.
 
 
 
 

Description

If you live in Newmarket or Newfields NH, please complete this form so that we can best serve you through the Newmarket Community Church Food Pantry.