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Christ Temple Church Lansing - Community Pantry Intake Form
Christ Temple Church Lansing is pleased to announce a charitable pantry as an outreach effort to assist the needs of our community.   As a community non-profit organization, it is our goal to meet the needs of the community with perishable and non-perishable food items, clothing, houseware, exceptional educational experiences or whatever the community need may be in line with the mission of Hope, Help, and Healing!

Christ Temple Church Lansing - Community Pantry is located at 1033 Lenore St., Lansing, MI.  Pantry distribution dates will be every 1st and 3rd Friday of the month from 3pm - 6pm.  

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Client Certification
The client certifies that the information/answers provided below will be complete and true.  You further agree to the following:
    -  You understand this community pantry is to be used as an emergency resource only and is meant to supplement additional  assistance or resources you may receive.
    -  Pantry items may be limited and will be provided until supplies are depleted.  As the client, I acknowledge it is my decision to accept items from this pantry and I relinquish Christ Temple Church Lansing - Community Food Pantry from all liability of any nature whatsoever and accepts perishable and non-perishable food and other items "AS IS" and at the clients own risk.
    -  There is no guarantee to the amount or type of food products given.
    -  The client will not sell the food or non-food products or exchange/barter any community pantry item received for services.  
    -  Inappropriate behavior such as profanity, 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 Christ Temple Church Lansing - Community Pantry.

If you agree to the above conditions, please continue to complete this form.  


Last Name: *
First Name: *
Phone: (home)
Phone: (cell)
E-mail Address:
Have you previously received assistance from the Christ Temple Church Lansing - Community Pantry?: *
Number of adults in the home: *
Number of children in the home: *
Ages of male child(ren):
0-1yr
2-4yr
5-7yr
8-10 yr
11-13yr
14-16yr
I do not have a male child
I do not have a male child.
Child 1
Child 2
Child 3
Child 4
Child 5
Clear selection
Ages of female child(ren):
0-1yr
2-4yr
5-7yr
8-10yr
11-13yr
14-16yr
I do not have a female child.
I do not have a female child.
Child 1
Child 2
Child 3
Child 4
Child 5
Clear selection
What are your family needs: *
Required
Thank you for completing this form.  Someone will contact you shortly to set up a time for your visit to the community pantry.  
Christ Temple Church Pantry - Staff Use ONLY
This section is for CTC Pantry Staff only.  Please fill out the information below for accurate record keeping.
Client Contact Date:
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Client Appointment Date:
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Client Appointment Time:
Time
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Intake Completion Date:
MM
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