Crockett Snack Shak Form

I no longer need to receive a bag of food. (Be sure you click "Submit" at the bottom of this form.)

True

Choose Up to 3 Protein Items

(A) Mexican chili beans (can) (B) pinto beans (can) (C) tuna in water (can) (D) chicken (can) (E) tuna lunches (pop top) (F) peanut butter (G) chili w/ beans (can) (H) ravioli w/ meat (can) (I) grilled chicken soup (pop top) (J) chunky beef soup (K) dehydrated refried beans w/ green chilies (bag) (L) black eye peas (can)

Please only choose 3 items.

Choose up to 2 VEGETABLE Items

(M) corn (N) green beans (O/P) spaghetti sauce & bag of spaghetti noodles **COUNTS AS (2) ITEMS**

Please only choose 2 items.

Choose 1 MILK Item

(Q) 1 milk, chocolate (R) 1 milk, white

Please only choose 1 item.

Choose up to 2 FRUIT Items

(S) mixed fruit cocktail (pop top) (T) pineapple tidbits (pop top) (U) mandarin oranges (pop top) (V) peaches (pop top) (W) assorted juices

Please only choose 2 items.

Choose up to 2 GRAIN Items

(X) oatmeal (instant variety pack) (Y) assorted cereal (2oz bowl) (Z) rice (bag) (AA) Ramen Noodles (beef flavor) (AB) Ramen Noodles (chicken flavor) (AC) macaroni and cheese dinner (box) (AD) saltine crackers (sleeve) (AE) pancake mix

Please only choose 2 items.

Choose 1 SNACK Item

(AF) cracker,cheese or peanut butter (AG) original beef stick (AH) honey roasted peanuts (AI) breakfast bar

Please only choose 1 item.

Choose 1 WATER Item

(AJ) bottled water No water for me

Please only choose 1 item.

Wufoo

Crockett Snack Shak Form

PROTEINS

VEGETABLES

MILK

FRUITS

GRAINS

SNACKS

WATER