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0 1 2 3 4 5 6 7 8 9 10	# of family members residing in your residence - Adults (13 or older) Free
0 1 2 3 4 5 6 7 8 9 10	# of family members residing in your residence - Children (12 or younger) Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 1:00 - 1:30 Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 1:30 - 2:00 Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 2:00 - 2:30 Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 2:30 - 3:00 Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 3:00 - 3:30 Free
0 1 2 3 4 5 6 7 8 9 10	Picking Up between 3:30 - 4:00 Free
0 1 2 3 4 5 6 7 8 9 10	I am unable to leave my home & need delivery Free Free
Notes
Total	$