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North Texas Food Bank Pantry Intake Form
Campus Location/Name:
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Name:
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City:
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State:
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Zip Code:
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Email:
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Phone Number:
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Number of People in Household:
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I am currently experiencing a food crisis (check all that apply):
The food I purchased did not last and I don't have enough money to get more.
I can't afford to eat balanced meals.
I cut the size of my meals or skipped meals because there wasn't enough money for food.
Other
1. Are you or anyone in your household on any form of government assistance, i.e. SNAP, TANF, WIC, etc.?
Yes
No
If no, are you interested in learning more about these assistance programs?
Yes
No
2. Are you or a member of your household currently employed?
Yes
No
3. Are you currently receiving Financial Aid?
Yes
No
4. Current Student Status (please select all that apply):
Full-Time
Part-Time
Traditional
Non-Traditional
Veteran
Other
Client Signature:
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Date:
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