Register for Food Pantry

Name*
First Last
Today's Date*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email Address*
Phone Number*
Number of People in Your Household:*
Are you currently receiving any form of government assistance, ie.. Food stamps, Social Security, etc.,? (Receiving government assistance as an income eligibility indicator, allowing food pantry staff to know you automatically are eligible to Receive USDA commodities.)*
CLOTHING ITEMS ONLY (PLEASE NOTE: CLOTHES CANNOT BE RETURNED OR EXCHANGED):
Please describe clothing desired (include, ages, and sizes)
CAPTCHA
Phone
This field is for validation purposes and should be left unchanged.

NOTICE TO CLIENTS

If you receive food from this emergency pantry, please note the following:

This pantry CANNOT:

Require you to provide a service, participate in a religious event or join any part of this organization as a condition of receiving food.
Refuse assistance to you based on race, color, age, religion, national origin, disability, gender, sexual orientation, or political affiliation.

This pantry must implement guidelines and post them where clients can see them stating the limitations that would affect service, stating the following:

Pantry days and hours of operation.
How often your household may visit this pantry
Form of identification. If any, necessary to receive food.
Any service area restrictions (Example: serves only specific zip code or school boundary).
Refuse service to individuals posing a health hazard, been verbally or physically abusive or have threatened harm to volunteers, staff or other clients.

PANTRY GUIDELINES MUST BE CLEARLY POSTED.

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