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BSA Shares
What is your employee ID number?
*
Phone Number
*
Date
*
Month
Month
Sep
Day
Day
18
Year
Year
2021
How many adults are in the household?
*
How many children are in the home and what are their ages?
*
PROTEINS
Choose up to 5 PROTEIN Items
(A) Mexican Chili Beans (can)
(B) Pinto Beans (can)
(C) Starkist Tuna in Water (pouch)
(D) Chicken (can)
(E) Starkist Tuna Lunch to Go
(F) JIF Peanut Butter To Go
(G) Wolf Brand Chili
(H) Spaghettio's
(I) Campbell's Healthy Request chicken w/ brown rice Soup
(J) Nature Valley protein bar
(K) Rosarita Refried Beans
(L) Bush's Black Beans
(M) Fairlife Chocolate Protein Drink (30g protein)
(N) Fairlife Protein Drink (30g protein)
(A) Protein Quantity?
(B) Protein Quantity?
(C) Protein Quantity?
(D) Protein Quantity?
(E) Protein Quantity?
(F) Protein Quantity?
(G) Protein Quantity?
(H) Protein Quantity
(I) Protein Quantity?
(J) Protein Quantity?
(K) Protein Quantity?
(L) Protein Quantity?
(M) Protein Quantity?
(N) Protein Quantity?
VEGETABLES
Choose up to 3 VEGETABLE Items
(N) Green Bean
(O) Del Monte Spaghetti Sauce
(P) Bag Spaghetti
(Q) Tomato Sauce
(R) Carrots
(S) Corn
(S) Quantity?
(N) Quantity?
(O) Quantity?
(P) Quantity?
(Q) Quantity?
(R) Quantity?
MILK - Shelf Stable
Choose Milk Items
(WH Milk) Fairlife White Milk (single serving size)
(CH Milk) Fairlife Chocolate Milk (single serving size)
(WH Milk) Quantity?
(CH Milk) Quantity?
FRUITS
Choose up to 3 FRUIT Items
(T) Dole Pinapple Tidbits
(U) Mandarin Oranges
(V) Peaches
(W) Mixed fruit cocktail
(T) Quantity?
(U) Quantity?
(V) Quantity?
(W) Quantity?
BEVERAGES
Choose BEVERAGE Items
(X) Gatorade
(X) Quantity?
GRAINS
Choose up to 4 GRAIN Items
(As_Cer) Assorted Cereal
(Br_Rice) Brown Rice (bag)
(Vel_MC) Velveeta shells Mac and Cheese
(Kraft_Cup) Kraft Mac N' Cheese Easy Cups
(Qua_Sing) Quaker Instant Oatmeal (variety) (single serving size)
(Salt_Crk) Saltine crackers
(Pan_Mix) Pancake Mix
(As_Cer) Grain Quantity?
(Br_Rice) Grain Quantity?
(Vel_MC) Grain Quantity?
(Kraft_Cup) Grain Quantity?
(Qua_Sing) Grain Quantity?
(Salt_Crk) Grain Quantity?
(Pan_Mix) Grain Quantity?
SNACKS
Choose SNACK Items
(CHZ_Its) Cheez Its
(Cer_Bar) Rice Krispie Cereal Bar
(Ap_Sa) Applesauce
(Beef_S) Jack Link Beef Stick
(Chz_Crk) Cheese and Cheddar Crackers
(S_Pop) Skinny Pop popcorn
(CHZ_Its) Quantity?
(Cer_Bar) Quantity?
(Ap_Sa) Quantity?
(Beef_S) Quantity?
(Chz_Crk) Quantity?
(S_Pop) Quantity?
DIAPERS
I would like diapers
No, thank you
Yes, I would like diapers
Diapers are available for children under the age of three and come in sizes preemie to seven. Pull-ups are also available in size 2T-5T. To receive diapers, please check the "Yes" mark above and call the Care Net Pregnancy Resource Center of Dumas at 806-935-3549 so that they can collect some additional information for grant reporting purposes. This offering will be available for a limited time.
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