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Blessing Box Request Form
December 2025
If you are in need of food assistance for the month of December, please fill out the form below. December distribution will take place on Saturday, December 20th, from 9 am to Noon. Thank you!
First Name
Last Name
Address
Apartment, suite, etc.
City
State
Zip/Postal Code
Email
Phone Number
Blessing Box Request Form
Please help us get to know you/your family and your needs so we can best help you.
How many people are in your household needing assistance with food?
1-2
3-4
5+
What are the ages of those in the household needing food assistance?
Do you have any dietary restrictions or food allergies? Please select all that apply.
Gluten Free
Dairy Free
Vegetarian
Other
None
If "other" please specify or if additional details are needed for the above question, please add them here. If none, please put "N/A".
Please select any and all options available to you for meal preparation/storage.
Stove top
Oven
Microwave
Air Fryer
Refrigerator
Freezer
Toaster Oven
None
We are located at 10411 Bailey Dr. NE in Lowell. Pick up date for this box is Saturday, December 20. Will you be able to pick up your blessing box or if you are in the Lowell area, will you need it delivered?
I can pick up.
I will need delivery.
I'm not sure at this time.
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