STUDENT FOOD BANK APPLICATION
APPLICANT INFORMATION:
Name:
Student ID Number:
Phone:
Email:
Address:
City:
Postal Code:
Number of people in your household:
Ages of the people in your household:
STATISTICAL INFORMATION:
Student Status:
o Full time Student
o Part time Student
o International Student
o Domestic Student
Program:
Gender:
o Female
o Male
o Prefer not to Disclose
PRIMARY REASON FOR VISIT:
o Low paying job/insufficient hours o High Rent/ Bills
o Insufficient funds from Student Loans/Grants o Unemployed
o Other (please explain):
INCOME AND EXPENSE INFORMATION:
TOTAL MONTHLY INCOME:
TOTAL MONTHLY EXPENSES:
ADDITIONAL INFORMATION:
Please provide any additional information that you feel supports your application for CUE Food Bank assistance.
DIETARY RESTRICTIONS/ALLERGIES:
o Vegetarian o No Nuts
o Gluten Free o Dairy Free
o Halal o No Pork
o Other:
STUDENT FOOD BANK APPLICATION
Concordia University of Edmonton’s Food Bank is coordinated through the Student Life and Learning Office and
the information provided will be kept confidential. Statistical information is collected for information purposes
only and will have no determination in the approval of the application.
Signature of applicant *if submitting online you will be required to sign when you pick
up the hamper
Date
Please submit completed application form to foodbank@concordia.ab.ca
Online submissions will receive a response within 48 hours.
FOR OFFICE USE ONLY:
APPROVED
APPROVAL REMAINS IN PLACE UNTIL: DATE
DECLINED
REASON FOR DECLINE:
NAME OF CUE EMPLOYEE:
SIGNATURE OF CUE EMPLOYEE: DATE
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