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Manzanita Outreach Home Delivery Form

If you are unable to find a proxy, home delivery services are available to residents on a limited basis. Please fill out this form below, and we will be in touch with you shortly.

You will receive a call that you will need to answer or call back in order to be added to the list so that we can confirm information before your first delivery.

You will also need to be signed up by the third Saturday of each month in order to receive a delivery that month.

You will need to be home to receive the delivery of food. If you are not home during a scheduled delivery, you will be removed from the home delivery list.

By filling out this form, you agree to our text and email communication and acknowledge you are within these income guidelines.

Who will the food be going to? *

First Name

Last Name

Date of birth of person receiving food: *

(mm/dd/yyyy)

Address of person receiving food: *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Phone number of person receiving food: *

Email of person receiving food: *

Verify Email *

Total number of people in this household: *

Number of people under 18 in this household: *

Special delivery instructions?

Please let us know if there are specific delivery instructions that are needed for our delivery drivers, such as if your address is difficult to find or if you need a gate code to enter the neighborhood. If there are no additional instructions, your deliveries will be made to your front porch or front door. Deliveries will not be brought into your home but instead will be left just outside your front door.