Fillable LMC Food Pantry Intake Form (Los Medanos College)

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LMC Food Pantry Intake Form (Los Medanos College)

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The LMC Food Pantry Intake Form (Los Medanos College) form is 1 page long and contains:

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File type: PDF

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LMC Food Pantry Intake Form
Student ID __________________________ Date ___________________
Please Print Clearly
Last Name
First Name
Phone
Email
Do we have permission to contact you? _____ Yes _____ No
How did you hear about the LMC Food Pantry?
___________________________________________________________________________
Household Size (household is defined as people who purchase and prepare food together)
# of children in household (0-6 years of age) ______
# of children in household (7-18 years of age) ______
# of adults in household (19-59 years of age) ______
# of adults in household (60+ years of age) ______
Have you applied for FAFSA? _____ Yes _____ No
If yes, were you approved? _____ Yes _____ No _____ Pending
If you have not completed a FAFSA application, what prevented you from doing so?
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Would you be in interested in learning about additional support services that may be available?
_____ Yes _____ No
Do you have any dietary limitations or allergies? _____ Yes _____ No
Please specify _________________________________________________________________
Student Signature __________________________________ Date ___________________
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LMC Food Pantry Intake Form (Los Medanos College)

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Completed 20 July 2020

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