Name *

First Name

Last Name

Phone *

(###)

###

####

Do you live in Lower Merion Township? *

Yes

No

How can we help? *

Please check all that apply.

Local Weekly Food Delivery (Please specify any dietary restrictions below)

Basic Needs Items (Please specify below)

Resource Connection (Please specify type below)

Other (Please specify below)

Household deliveries are made every Thursday. Do you need a starter package delivered before then?

Yes

Do you have a female head of household? *

Yes

No

I confirm all information provided is true and correct from date of initial service by NHN. *

Confirm