The Food Pantry Intake Form                     Survey

1.First and Last Name

2.DVC Student identification number

3.DVC email address

4.Current Address

Name

Address

City/Town

State/Province

ZIP/Postal Code

County of residence

Email Address

Phone Number

5.Are you currently employed?

Yes

No

6.How many people live in your household?

7.How many people in your household are under the age of 18?

8.Are you currently an UMOJA student?

Yes

No

9.Do you receive CalWORKS benefits?

Yes

No

10.Are you currently enrolled in at least one CE course?

Yes

No

11.Are you currently enrolled in a CE certificate or degree program?

Yes

No

12.Do you currently receive CalFresh benefits?

Yes

No

13.If you do not receive Cal Fresh benefits up to $200 a month, go to the CalFresh application now and apply.

14.*Acceptance of free food and waiver liability.

I understand that food can only be picked up by the currently enrolled Diablo Valley College student who completed this intake form.

I understand that food I receive from the Diablo Valley College Food Pantry has been purchased from off-campus partners and that none of the parties or groups involved in the program make any guarantees as to the quality of the food or its value for any particular purpose. Diablo Valley College does examine content integrity but does not guarantee any such admissions or claims.

I understand that some of the food distributed at the Diablo Valley College Food Pantry may have surpassed its "Best By" consumption date. The USDA states that "best if used by or before" date is recommended for best flavor or quality. It is not a purchase or safety date.

By signing below, I release Diablo Valley College and the original donor from any liability or harm or losses in connection with the food or supplies I have received. I assume any risks and covenant not to sue the released parties with respect to such harm or losses.

I will only request and take items that I reasonably expect myself and/or my family to use. I understand that the DVC Food Pantry cannot guarantee that it will have food available, but can suggest additional community locations and resources.

A "Best if Used By/Before" indicates when a product will be of best flavor or quality.

It is not a purchase or safety date. A "Sell-By" date tells the store how long to display the product for sale for inventory management. A "Use-By" date is the last date recommended for the use of the product while at peak quality, for example, December 14, 2016.

By checking this box I acknowledge receipt of free food from the DVC Food Pantry.

15.I acknowledge receipt of free food from the DVC Food Pantry.

Yes

No

16.Signature:

Date / Time

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

The Food Pantry Intake Form

Welcome to The Food Pantry!