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?

Yes

No

How many?

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?

Yes

No

The Food Stamp Program helps low-income individuals buy food. Are you a receiving member of this program?

Yes

No

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

Yes

Please list items you are in need of

Community Cart Staff/Faculty Request Form

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