NAME:______________________________

 

AGE:________________________________

 

ADDRESS:_________________________________________________________

 

CONTACT NUMBER:_________________________________________________

 

SPONSOR:_________________________________________________________

 

IDENTIFICATION NUMBER:___________________________________________

 

VERIFICATION INFORMATION:________________________________________

______________________________________________________________________________________________________________________________________

 

DATE OF VISIT:_____________________________________________________

 

NUMBER OF BAGS  RECEIVED:_______________________________________

 

NUMBER OF FAMILY MEMBERS:______________________________________

 

 

EVERY FIRST TUESDAY OF THE MONTH: 6 P.M.

–

9 P.M.

EVERY FIRST FRIDAY OF THE MONTH: 12 P.M.

–

3 P.M.

EVERY FIRST SATURDAY OF THE MONTH:

8 A.M.

–

11 A.M.