FMSM's Food & Clothing Pantry Intake Form

FEED MY SHEEP MINISTRY’S FOOD PANTRY INTAKE FORM
Name/Nombre *

First NameLast Name
Address/ Dirección *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number/ Número de teléfono
Please enter a valid phone number.Format: (000) 000-0000.
Date of Birth/ Fecha de nacimiento *

MonthDayYear
Date
Email/ Correo electrónico *
example@example.com
Total Household Gross Income*
Number of Household Members/ Número de miembros del hogar*
Household Crisis Eligibility/ Elegibilidad para crisis del hogar
If household is eligible for household crisis food needs, documents reason for crisis here/ Si el hogar es elegible para las necesidades alimentarias de crisis del hogar, documente el motivo de la crisis aquí
Food PantryHygiene Products (based on availability)Diapers & Wipes (based on availability)Prayer requestCounselingOther
YesNo
Supplemental Nutrition Assistance Program (SNAP)/ Programa de Asistencia Nutricional Suplementaria (SNAP)Temporary Assistance for Needy Families (TANF)/ Asistencia Temporal para Familias Necesitadas (TANF)Supplemental Security Income (SSI)/ Ingreso de Seguridad Suplementario (SSI)National School Lunch Program (NSLP) free or reduced lunch/ Programa Nacional de Almuerzos Escolares (NSLP) almuerzo gratuito o reducidoMedicaid/ Seguro de enfermedadUnemployed/DesempleadasFull/Part Time Employed/ Empleados a tiempo completo/parcialOther
Appointment Times are MONDAY BY LIMITED APPOINTMENT ONLY, TUES WEDNES & FRI 10AM-3PM CLOSED THURSDAY AND SUNDAY available every 2nd & 4th Saturday 10am-2pm/ El horario de atención es: LUNES CON CITA PREVIA LIMITADA, MARTES, MIÉRCOLES Y VIERNES de 10:00 a 15:00. CERRADO LOS JUEVES Y DOMINGOS. Disponible el segundo y cuarto sábado de cada mes de 10:00 a 14:00.*
Community Food Pantry Policy and Procedures

Confidentiality Statement:
"All information provided in this form will be kept confidential and will only be used for the purpose of assessing your needs and providing assistance. We respect your privacy and will not share your information with third parties without your consent, except as required by law."

Liability Disclaimer:
"FMSM is not liable for any injuries, losses, or damages that may occur as a result of using the services provided by the food and clothing pantry. By signing this form, you acknowledge and accept this disclaimer."

Accuracy of Information:
"By submitting this form, you affirm that the information provided is true and accurate to the best of your knowledge. Providing false information may result in disqualification from receiving services."

Right to Refuse Service:
"FMSM reserves the right to refuse service to any individual who does not meet eligibility criteria or who engages in inappropriate behavior."

No Guarantee of Services:
"Completion of this form does not guarantee assistance. Services are subject to availability and eligibility requirements."

Changes to Policy:
"FMSM reserves the right to modify its policies and procedures regarding the food and clothing pantry at any time without prior notice."

Acknowledgment of Understanding:
"By signing this form, you acknowledge that there may be a photo/video of you posted on our website, flyers, or social media platform and you have read and understood the disclaimers and agree to comply with the policies of FMSM."

Feedback Mechanism:
Clients and community members are encouraged to provide feedback on pantry services. This can be done through:

- Like, Share, & Follow us on social media platforms: https://www.facebook.com/fmsmtx, https://www.instagram.com/feedmysheepministry21/,

- FMSM's Website: https://www.fmsmtx21.org/

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***You will receive a confirmation email of placing your order. PICK UP ORDERS ONLY NO ORDERS WILL BE SHIPPED!!!

Recibirá un correo electrónico de confirmación de la realización de su pedido. SOLO PEDIDOS DE RECOGIDA.
LOCATION FOR PICK UP ORDERS: 2026 W. Pioneer Pkwy, Ste. C6, Pantego, Tx 76013 (Behind a blue building called Armstrong Tire)

PLEASE CALL/TEXT 817-330-9707 IF YOU CAN'T ARRIVE FOR YOUR PICK UP TIME TO RESCHEDULE. IF YOU ARE MORE THAN 15 MINUTES LATE YOU WILL NEED TO RESCHEDULE.

UBICACIÓN PARA RECOGER PEDIDOS:2026 W. Pioneer Pkwy, Suite C6, Pantego, TX 76013 (Detrás de un edificio azul llamado Armstrong Tire)

SI NO PUEDE LLEGAR A LA HORA DE RECOGIDA, LLAME O ENVÍE UN MENSAJE DE TEXTO AL 817-330-9707 PARA REPROGRAMAR SU RESERVA. SI LLEGA CON MÁS DE 15 MINUTOS DE RETRASO, DEBERÁ REPROGRAMAR SU RESERVA.
Please verify that you are human*
Signature/ Firma
Should be Empty:

FEED MY SHEEP MINISTRY’S FOOD PANTRY INTAKE FORM