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ACC - Food Pantry Request Form
Currently enrolled students may request a pre-packaged bag of grocery items up to once a week on an emergency bases until a larger supported Food Pantry can be accessed, as supplies are limited. Please complete the questions below to better help us serve you. You will receive a confirmation call or email when your requested groceries are ready for pick-up. Please bring your student ID at time of pick-up.
Name (First and Last) *
Student ID number *
Birthdate *
MM
/
DD
/
YYYY
Phone Number *
Email Address *
Do you have any food allergies? *
If yes, please list all food allergies.
Do you have children in the home? *
If yes, what are their ages and do they have allergies?
Is there a greater need for a particular meal?
Clear selection
Would you like to receive any toiletry items? *
Would you like to receive any feminine products?
Clear selection
Would you like to discuss community resources referrals with a counselor in the Single Stop Office? *
Submit
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