Mitchell Food Pantry Questionnaire

Mitchell Food Pantry Questionnaire
Personal Information:
Full Name

First NameMiddle NameLast Name
Student ID#
Phone Number
Questions and Details:
Household Size
How many children live in the home? (Ages 0-17)
Do you receive food stamps/SNAP benefits?

YesNo
Please indicate all kitchen housewares that ARE available to you.

Oven/toaster ovenStove top/hot plateMicrowaveCan openerUtensilsPlates, bowls, etc.Refrigerator
Are there any allergies (food related) or additional information we should know?
After completing the form, a staff member will reach out to you about selecting a pick up time.

Pick up will be in the Eason Student Services building on Main campus (Statesville).
Should be Empty: