| First Name |
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| Last Name |
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| Date Of Birth |
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| Email |
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| Mailing List |
do you want to receive our newsletter and occasional announcements?
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| Address |
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| City |
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| State |
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| Country |
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| Zip Code |
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| Phone |
Your primary contact number
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| Household Info |
List names, ages and relationships of household family members.
|
| Total number of household members under 18 |
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| Total number of household members over18 |
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| Total number of household members over 65 |
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| I have access to: |
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| Does your family receive any type of assistance? |
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| OTHER NON-EMPLOYMENT INCOME: |
(please explain)
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| The total gross yearly income before deductions of all household members: |
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| The total gross monthly income before deductions of all household members: |
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| Where are you currently employed? |
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| Employer’s Phone Number |
(We won’t embarrass you, but we will call to ensure you are employed.)
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| If not currently employed, please explain why. |
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| What is your next step for finding employment? |
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| Was there an emergency situation that caused you to need food? |
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| What can we pray with you about today? |
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| Do you attend a church? |
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| Have you shared your need with a church? |
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| Church name |
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| Would you be interested in a link to Oakdale Church or Mount Paran Church online services? |
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| Would you like to have one of our volunteers accompany you at one of these two churches? |
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| Agreement |
The undersigned client certifies that the information/answers provided are complete and true. You further agree
to the following:
• I understand that this food pantry is to be used as an emergency resource only and is meant to
supplement additional assistance or resources you may receive for no more than 6 months.
• Food is provided on a FIRST COME, FIRST SERVED basis and I relinquish this Food Pantry and of
all liability of any nature whatsoever and accept the food “AS IS” and at my own risk.
• There is no guarantee to the amount or type of food product given.
• I will not sell the food or non-food products or exchange/barter food or non-food products for
services.
• Inappropriate behavior such as profanity, verbal abuse of staff, or any other disruptive behavior is
prohibited. Any such behavior may result in the suspension or termination of my privileges at this food
pantry.
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