UC Blue Ash Student Food Pantry Intake
Name
*
First Name
Last Name
UC Email Address
*
example@mail.uc.edu
M Number
*
Please leave best phone number to reach you
How can we suit your dietary needs? ( e.g. vegetarian, vegan, kosher, gluten free)
Would you like to be contacted for support with accessing other resources such as housing, food, clothing, or mental health services?
*
Yes
No
Please list the best phone number to reach you. If you do not have a phone, we will contact you by your UC email.
*
-
Area Code
Phone Number
Time
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Hour
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Minutes
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AM/PM Option
Please provide any feedback:
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