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Community Cart Staff/Faculty Request Form
COMMUNITY CART REQUEST FORM
Please complete the form to the best of your ability. Some fields are required. Forms are submitted directly to Student Diversity Initiatives. The information provided from this form will only be seen by the staff responsible for the food pantry and used for internal reporting. Personal information will be kept confidential and only statistical information will be used. Information given on this application will not affect your use of the Community Cart Food Pantry.
Email Address
First Name
Last Name
Employee ID
Are there children under 18 in your household you are financially responsible for?
Are there children under 18 in your household you are financially responsible for?
Yes
No
How many?
Are there senior citizens (60+) in your household you are financially responsible for?
Are there senior citizens (60+) in your household you are financially responsible for?
Yes
No
How many?
Temporary Assistance for Needy Families (TANF) is a cash assistance program for families with children. Are you a receiving member of this program?
Temporary Assistance for Needy Families (TANF) is a cash assistance program for families with children. Are you a receiving member of this program?
Yes
No
The Food Stamp Program helps low-income individuals buy food. Are you a receiving member of this program?
The Food Stamp Program helps low-income individuals buy food. Are you a receiving member of this program?
Yes
No
Please check the following items you will use. Please note this information is used for guidance in stocking and filling requests. **Some items may not be available at this time but potentially available later**
Please check the following items you will use. Please note this information is used for guidance in stocking and filling requests. **Some items may not be available at this time but potentially available later**
All Items
Almond Milk
Dairy Milk
Fresh Produce (Seasonal)
Frozen Chicken (whole pieces)
Ground Hamburger
Frozen Meats
Breaded Chicken Patties
Italian Sausage
Frozen Meals
Frozen Vegetables
Oatmeal
Granola Bars
Canned Vegetables
Canned Fruit
Canned Pasta
Peanut Butter
Ramen
Dry Pasta
Canned Beans
Sauces
Spaghetti Sauce
Fruit Juice
Water
Mac and Cheese
Boxed Meals
Crackers
Cake Mix
Snacks/Cookies
Baby Cereal (+6 Months)
Household Cleaning Supplies (please list below the items needed)
Hygiene Products (please list below the items needed)
Small Household Items (please list below the items needed)
Please list other items you are in need of, specific items you would like to receive or items you do not want to receive (Example: I do not want peas, corn, black beans. I would like peaches and green beans, etc.) (I am in need of a crockpot) (i am in need of shampoo, toilet paper, bath soap) :
Acceptance of Free Food and Waiver of Liability
By typing my name below, I acknowledge receipt of free food from the Community Cart Food Pantry. I understand this is a gift and not a reoccurring obligation by Missouri S&T or the Community Cart Food Pantry. I further understand and agree that by accepting this donated food I freely and voluntarily, with full knowledge, hold harmless and in no way liable or responsible for the quality, condition or packaging of the food, Missouri S&T, its officers, agents, employees, students, volunteers, and food suppliers.
Name
Accept
Accept
Yes
Submit
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