Please enter your information below. Fields labeled with * are required. Any information you submit will be used in accordance with our Privacy Policy.

School Group and Personal Information

*School/Group Name:

*School/Group Visit Date:

*First Name:

*Last Name:

*Address:

*City:

*State (two characters):

*County   Alamance Alexander Alleghany Anson Ashe Avery Beaufort Bertie Bladen Brunswick Buncombe Burke Cabarrus Caldwell Camden Carteret Caswell Catawba Chatham Cherokee Chowan Clay Cleveland Columbus Craven Cumberland Currituck Dare Davidson Davie Duplin Durham Edgecombe Forsyth Franklin Gaston Gates Graham Granville Greene Guilford Halifax Harnett Haywood Henderson Hertford Hoke Hyde Iredell Jackson Johnston Jones Lee Lenior Lincoln Macon Madison Martin McDowell Mecklenburg Mitchell Montgomery Moore Nash New Hanover Northampton Onslow Orange Pamlico Pasquotank Pender Perquimans Person Pitt Polk Randolph Richmond Robeson Rockingham Rowan Rutherford Sampson Scotland Stanly Stokes Surry Swaim Transylvania Tyrell Union Vance Wake Warren Washington Watauga Wayne Wilkes Wilson Yadkin Yancey

*Zip Code:

*Contact Phone: (xxx-xxx-xxxx)

Fax Number: (xxx-xxx-xxxx)

*E-mail Address:

*E-mail Address (re-enter):

*Preferred Pick-up Time:

Time subject to availability ( pick-ups are set in 15 minute intervals) - please check your lunch confirmation for your scheduled time.

Lunch pick-up location is Junction Springs Cafe. Other pick-up locations are available with prior arrangement; please call 336-879-7357.

*Number of Hamburger Meals:

*Number of Hot Dog Meals:

*Number of Uncrustables PB&J Sandwich Meals:

*Number of Ham Sandwich Meals:

*Number of Milks:

*Number of Capri Suns:

Total cost: