Saluki Food Pantry First Time Application

Please read:

Please complete the form to the best of your ability. Printed forms may be picked up at the Saluki Food Pantry during open hours. 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 Saluki Food Pantry.

*A new application will need to be completed each academic year to verify information.*

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* 1. General Information

First Name

Last Name

Phone Number

Preferred Email Address

Dawg Tag Number

Age

Major

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* 2. Household Information. (Answers to household information will not impact your ability to receive food)

Do you have a partner that you share finances with? (Not including roommates, unless you are financially responsible for that individual)

Is your partner an SIU Student? Yes or No

Do you have children you are financially responsible for?

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* 3. How many hours do you work per week?

1-10

11-20

21-30

31-40

40+

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* 4. Which most closely describes your gender?

Woman

Man

Genderqueer or non-binary

Agender

Prefer not to answer

Gender not listed. My gender is

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* 5. Citizenship

U.S Citizen

International Student/Foreign

Permanent Resident

Other (please specify)

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* 6. Are you a full time student?

Yes

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* 7. Are you a first generation student? (A first generation student is someone who neither their parents nor grandparents attended college.)

Yes

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* 8. Please check one or more of the following groups in which you consider yourself to be a member:

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific

White

Hispanic or Latino/Latina

Identity not listed

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* 9. Are you a Veteran of the US Armed Forces?

Yes

Other (please specify)

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* 10. Are you an Active Duty servicemember in the US Armed Forces?

Yes

Other (please specify)

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* 11. Classification

Freshman

Sophomore

Junior

Senior

Graduate Student

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* 12. What type of housing do you currently have?

Off campus without a meal plan

Off campus with a meal plan

On campus without a meal plan

On campus with a meal plan

Homeless

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* 13. Please list the names of people living in your household and their age, for who you need food and are financially responsible for.

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* 14. Are you currently receiving any form of government assistance, i.e. Food Stamps, Social Security, etc.? Please list:

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* 15. Are there any additional needs, other than food, that we can provide information on? (counseling, food stamps, shelter, household supplies, tutoring, etc.) *Information may come in-person or in a follow-up email.

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* 16. Have you used the Saluki Food Pantry before?

Yes

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* 17. How did you hear about the Saluki Food Pantry?

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* 18. Acceptance of Free Food and Waiver of Liability

By typing my name below, I acknowledge receipt of free food from the Southern Illinois University Carbondale Saluki Food Pantry. I understand this is a gift and not a reoccurring obligation by SIUC or the Saluki 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, SIUC, its officers, agents, employees, students, volunteers, and food suppliers. I also acknowledge that I may visit the food pantry one time per month.

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