Food Pantry Intake Form

The Corner Pantry at Grace's Closet

Fill out the form below in order to sign up to receive food from our pantry.
When siging up for our food pantry program, please adhere to the below guidelines:
1. Pantry pickup is by registration only.
2. Pickup is per household and is currently limited to once per month, to maintain adequate supply. Only one registration per household will be accepted.
3. ID must be shown at time of pickup for verification purposes. No exceptions.
4. Please fill out our form to schedule a pickup. This registration is separate from any Grace's Closet appointment scheduling.
Is this your first time receiving groceries from us via our food pantry?*

YesNo
Food pantry pickups are limited to once per month PER household. By scheduling, you acknowledge that you have not picked up less than a month ago.*

Yes - I acknowledge that I haven't picked up less than a month ago for my household.
Your Full Name*

First NameLast Name
Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Your E-mail*
example@example.com
Gender*

MaleFemale
Are you married or single?*

MarriedSingle
Are you currently employed?*

YesNo
Do you have children under the age of 18?*
How large is your household?*
Please check all that apply regarding any additional assistance your household receives.*

No one in the household receives assistance.SNAP/EBTUnemployment/DisabilityCash AssistanceWICOther
Note: We collect the information above to help us better understand the needs and backgrounds of those that we are serving.
Currently, visits are limited to once per month. Your ID must be shown at the time of pickup. Please do not submit more than one registration per month.

Note: We will contact you with a day and time to pick up your groceries.
Food Pantry Pickup Dates and Times Available*
Should be Empty: