Bethel Church

Food Pantry Intake Form

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First Name Last Name
Address
Address Line 2
City State Zip Code

Phone Number
Phone Number
Email Address




Select one
Yes
No




Select all that apply
Stove Top
Oven
Microwave
Can Opener
Running Water
*None of the above



The undersigned client certifies that the information/answers provided are complete and true and further agree to: ~ You understand that the Bethel Food Pantry is to be used as an emergency resource only and is meant to supplement additional assistance or resources you may receive. ~ Food is provided on a FIRST COME, FIRST SERVE basis and you relinquish the Bethel Food Pantry of all liability of any nature whatsoever and accept the food *AS IS* AND AT YOUR OWN RISK. ~ There is no guarantee to the amount or type of food or produce given. ~ You will not sell the food or non-food products or exchange/barter food or non-food products for services. ~ Inappropriate behavior such as profanity, littering, verbal abuse of staff or any other disruptive behavior is prohibited. Any such behavior may result in the suspension or termination of your privileges at the Bethel’s Food Pantry. *None of the above: Bethel Pantry will provide you with ready-to-eat food items. (these are limited)

AGENCY USE ONLY

Date Received:_____________________ Date Filled:_________________ Date Picked Up:______________ Intake Staff Signature:________________________________________
* required