Service Agencies Form

—Get rescued food and focus on your clients

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Service Agencies

"*" indicates required fields

City*Name of Agency*

Address*

Street Address

Address Line 2

City

Province

Postal Code

Contact Name*

First

Last

Contact Email*

Contact Phone Number*

Demographic (Other)*If you selected other, please specify.

Social Service (Other)*If you selected other, please specify.

What type(s) of food program would donations be used for?*

Breakfast Program

Lunch Program

After School Program

Shelter or Drop-In Meal Service

Soup Kitchen

Hampers

Emergency Food Provisions (including snacks)

Door Service

Other

Food Program (Other)*If you selected other, please specify. How many unique individuals do you serve per week or month?* How many meals (or equivalencies) do you serve per week?*

Which of the below foods can you accept?*

Select all that apply. Please note: not all of these foods are available in all cities. Food is subject to availability of donations.

Bread (may be unsliced)

Pastries

Fruits

Vegetables

Frozen entrees (lasagna, meats, etc.)

Milk (if yes, you must have a refrigerator to store)

How many loaves of bread can you store?*

Do you have a kitchen where you can prepare food?*

Yes

No

What are your hours of operation?*Please indicate if you operate over the weekend. Business HoursThis is a content placeholder. Preview this form to view the Business Hours field.When can you accept donations?*Please list the days of the week and the time windows for each day—the broader the better. Business HoursThis is a content placeholder. Preview this form to view the Business Hours field.

When can you accept donations? (Anytime)

Anytime during business hours

How frequently would you like to receive donations?*Be advised that we may not be able to meet your request for frequency.

Do you have staff or volunteers who would be able to pick-up food from the donating vendor?*

Yes

No

Please list any special instructions for drop-offs?*(i.e. location, what buzzer to ring, where to park, who
to ask for)

Do you consent to Leftovers sharing posts and pictures about your organization?*

Yes

No

Please type your social media handles below.*(eg. Instagram, Facebook, Twitter handle, hashtags, etc.)Date of Submission*

MM slash DD slash YYYY

Respect Agreement*

For more information on Leftovers IDEA (Inclusiveness, Diversity, Equity and Accessibility) initiatives, go to https://rescuefood.ca/IDEA

I understand that Leftovers operates on the principles of respect, inclusiveness, diversity, and anti-racism.

Respect Agreement 2*

I recognize that Leftovers includes people of all races, genders, sexual orientations and religious beliefs in our recruitment of staff, volunteers, growers and partner organizations.

Respect Agreement 3*

I agree to demonstrate respect for all people and property when I’m participating in Leftovers programming.

Respect Agreement 4*

I acknowledge that Leftovers puts the safety of all individuals first.

By submitting this form, I agree that:*

Our organization has read the AHS Guidelines and understand that it is our responsibility to comply

By submitting this form, I agree that:*

Our organization has read the Leftovers Food Donation Guidelines and understand that it is our responsibility to comply

I also agree that:*

Our organization will not accept any foods listed as unacceptable in the AHS Guidelines

I also agree that:*

Our organization will not accept any foods listed as unacceptable in the Leftovers Food Donation Guidelines

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Service Agencies Form

—Get rescued food and focus on your clients