Long Beach Food Pantry Delivery Registration Form

The service areas for Long Beach Food Pantry Delivery include all zip codes in the city of Long Beach, as well as the following surrounding cities/zip codes: Signal Hill (90755 and 90807), Lomita (90717), Harbor City (90710), San Pedro (90731, 90732, 90733, and 90734), Carson (90745, 90746, 90747, 90749, and 90895), Wilmington (90744), and Paramount (90723).

To register your interest, please complete the form below and press the submit button. Once we receive your registration form, we will contact you within 24 hours.

First name*

Last name*

Referrer Name (If Applicable)

Referrer Email (If Applicable)

Referrer Phone (If Applicable)

Program you are applying to*

Please check box.

Long Beach Food Pantry Delivery

Application Date*

Today

Month/Day/Year

Date of birth*

Street address*

City*

Zip Code

Name of Complex/Living facility

You or a family member have a disability prevents you from accessing our food pantry locations?*

How often do you want food pantry delivery? ($10 fee per delivery)?

Please provide a working phone number for our driver to contact your prior to delivery.

Phone number

Mobile phone number

Email*

Demographic Information:

Gender

Are you a Veteran

Marital status

Ethnicity

What is your primary language?

Living Situation:

Physical Qualifications for Program:

Are you able to cook your own meals?

List any foods you dislike and would like to have omitted:

Are there any foods your doctor recommends you have more of?

What type of groceries would you like to receive?

Occasionally, we receive rescued food from local markets, including items close to the sell-by date. They can include specialty foods like crackers, cereal, meats, cheese, vegetables, etc. Are you open to receiving rescued food?

Do you have CalFresh?

If you don't receive CalFresh, are you interested in applying?

Geographic Information

Do you live in an apartment, house and or gated community?

What color is your house/apartment building?

What are the nearest cross streets to your home?

If you are not home, drivers will leave your groceries at your front door, ring the doorbell or knock to receive your delivery.