Mobile Food Registration

Select Pick Up location *

Saturday, April 24, 2021, 10am-11am - The Life Church Austin Peay - 3683 Austin Peay Highway

Name *

First Name Last Name

Date Of Birth *

Date

Gender *

Veteran *

Phone Number *

Area Code Phone Number

Cell Number *

Area Code Phone Number

Email *

example@example.com

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Pick Up Person Name *

First Name Last Name

Pick Up Person Date Of Birth

Date

HOUSEHOLD INFORMATION

Please list how many people live in the household

*Including head of household

Adults *

(18-59 years of age)

Children *

(0-17 years of age)

Seniors *

(60+ years of age)

List all household members. If additional space is needed, list additional members in the section below the chart. *

Please use this to add any additional household members.

Make sure to include name, date of birth, gender and if they are a veteran.

Please indicate emergency situation:

Which of the following programs do you participate in? *

Food Stamps (SNAP) Temporary Assistance to Needy Families Supplemental Social Security Residence to Public Housing Low Income Home Energy Assistance Program Not Applicable [Please select monthly income below]

Monthly Income

Privacy Policy Summary

1. Reading this Summary document is not a substitute for reading the PantryTrak Privacy Policy in full.

2. Food banks, food pantries, and other service providers that use the PantryTrak System, have agreed to the terms of a Master Subscription Services Agreement that includes adherence to this Privacy Policy.

3. The Privacy Policy acknowledges that Personal Data is being collected in conjunction with your request for service.

4. Personal Data may include, but is not limited to: (a) first and last name, (b) home address, (c) date of birth and/or age (d) email address, (e) mobile and/or home phone number, (f) income information, (g) employment information, and (h) family, household, and/or dependent information.

5. Personal Data will not be sold for direct marketing purposes.

6. The Privacy Policy may change at any time; the most current version can be found at www.pantrytrak.com/privacy

I certify that the information and income listed is true and correct, that I received food assistance, and that no other member of my household has applied for and received food during this distribution. I understand that misrepresentation of need, or sale, or exchange of food is prohibited.

SIGNATURE OF HEAD OF HOUSEHOLD *

Clear

This program is available to all eligible recipients regardless of race, color, national origin, age, sex, sexual orientation, or handicap.