Pantry Intake Form

Date

Month

Day

Year

First name

Last name

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Are you currently receiving any form of government assistance, ie: Food Stamps, Social Security etc.?

Receiving government assistance is an income eligibility indicator, allowing food pantry staff to know you automatically are eligible to receive USDA commodities.

NOTICE TO CLIENTS

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

This Pantry CANNOT:

Charge a fee or accept monetary donations for exchange for food and non-food items you receive.
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 any 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 necessary to receive food.
Any service area restrictions (Example: serve 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.