Food Insecurity Intake Form

Food Insecurity Intake Form

The Brooklyn College Food Insecurity program operates on limited funds and in support of others.

YOU ONLY HAVE TO COMPLETE THIS FORM ONCE
DO NOT RESUBMIT

Please provide the following information about yourself:
Enter your first and last name as it appears in CUNYFirst*

First NameLast Name
EMPLID*
Email*
example@example.com
Phone*
Preferred Contact Method*
Please list the total number of people in your household who may benefit from the BC Food Assistance and other related services:
# of Adults*
How many are Brooklyn College students?*
# of Children 0-5 years old*
# of Children 6-18 years old*
Student Status:*

UndergraduateGraduateFeirstein Graduate
Assistance/Information Needed:*

Fresh Food: periodic produce offeringsFood Pantry: a wide variety of fruit, veggies, grains, proteins, and toiletries (pickup available twice a month)Food Vouchers: $10 per class day toward lunch at BK Eats Cafeteria, Ovi's Place, Jupioca, or Brooklyn's Best Eats (pickup available weekly)External Food: grocery store gift cards to Key Food, Food Emporium, Food Universe, SuperFresh, Food Dynasty (pickup available monthly)Social Services: meet with a social worker for help with housing, health insurance, and other resources
Current Source of Income/Resources:*

Financial AidFamily SupportOn-Campus JobOff-Campus JobOther Support
How did you hear about the Brooklyn College food assistance program? If you were referred, please list the name of the person or campus department that made the referral.*
Please read the following statement before signing:

I understand that the Brooklyn College Food Insecurity program operates on limited funds and in support of others. I understand I may be contacted by the Brooklyn College Nutritionist and Case Manager to provide me information. I will not abuse the services of the Brooklyn College Food Assistance program. I will only request and take what I reasonably expect myself and/or my family to use.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Food Insecurity Intake Form

Please read the following statement before signing: