By checking this statement I understand that I release G.R.O.W. rooted in love Maternity Home and all affiliates from any liability with regards to possible spoilage or food-borne illness from products removed from The T.R.E.E. House - Walkerton. I understand that all items offered are NEAR or PAST its “best before” and/or "expiry" date. I agree that I am using this program at my own risk. I accept full responsibility for removal and safe storage of the removed food. *

I HAVE READ THE ABOVE STATEMENT, UNDERSTAND. AND AGREE.

I HAVE READ THE ABOVE STATEMENT DO NOT UNDERSTAND AND NEED MORE INFORMATION.

Name *

First Name

Last Name

Phone *

(###)

###

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What are the ages of your family members? *

0-5

6-12

13-19

Over 20

I understand that my information is confidential and not shared with anyone. I understand that my name will not be disclosed for any reason. I understand that my location, ages and family size information is used for statistic reporting only. *

YES

NO

I understand that these items are not to be sold and if reselling of items is brought to your attention I will automatically be forfeiting my pantry privileges. *

YES

NO

I understand that there is only ONE pick up per family and it is not permitted to send photos from other accounts and if this is brought to your attention I will automatically be forfeiting my pantry privileges. *

YES

NO

I have sent screenshots of items I would like to Momma B's Pantry Facebook page and waiting to be contacted with pick up instructions via Facebook Messenger *

YES

NO

Name: *

First Name

Last Name

Phone:

(###)

###

####

Name: *

First Name

Last Name

Phone:

(###)

###

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Date of Loss: *

MM

DD

YYYY