Mitchell Food Pantry Questionnaire

Mitchell Food Pantry Request Form
Personal Information:
Full Name

First NameMiddle NameLast Name
Student ID#
Phone Number
Questions and Details:

We ask the next few questions because our food donor partner uses this information to better understand and report how their donations help students and families at Mitchell. Your answers make a difference in keeping the pantry stocked.
Household Size
How many seniors live in the home? (Ages 60 and up)
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?
How often do you anticipate needing assistance?

One timeMonthlyBi-Weekly
Where would you like to pick up?
After completing the form, a staff member will reach out to you about selecting a pick up time and location.
What to Expect

Check in with pantry staff and have a photo ID. Visits are quick, private, and judgment-free. Bring an insulated bag, if possible, to take refrigerated and frozen items last so they stay safe.
Should be Empty:

Mitchell Food Pantry Request Form