• Pantry Intake

    Please use this form to start the process for food pantry service from Waller Assistance & Restoration Ministries, Inc.

  • Personal Information

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    Pick a Date

  • Demographics

  • Household Members

    This section is optional and will not affect your ability to receive USDA foods through The Emergency Food Assistance Program (TEFAP).

  • Release Agreement

  • Verification and Consent

    I certify that:

    1. I am a member of the household living at the address provided and, on behalf of the household, I am applying for USDA Foods that are distributed through the Emergency Food Assistance Program
    2. The answers to all questions and any statements I have made are true and correct to the best of my knowledge and belief.
    3. I agree to give the WARM staff any information necessary to prove statements about my eligibility.

    I understand that this application will be considered without regard to race, color, religion, creeds, national origin, age, sex, handicap, or political belief.

    Release of Information

    I hereby authorize WARM to release information about me and those in my household. I further release WARM from all legal responsibility of liability that may arise from this release. This Release of Information will remain in effect for three (3) years from the date noted under my signature at the bottom of this page unless I make a formal request to WARM that I no longer wish to participate in its Assistance programs.

    Hold Harmless and Indemnification

    I hereby release, forever discharge, and hold harmless WARM and the Officers, Directors, Employees and Volunteers thereof, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses.
     
    We intend claims to mean any and all demands, rights, claims, damages, suits, actions, costs and fees that you may have against WARM that may arise, directly or indirectly, through the provision by WARM of services, programs, facility use, consumption of food or food products, and/or any other incident arising on WARM property or premises, or related to WARM property, including claims and damages arising in whole or in part from the negligence of WARM, its Officers, Directors, Employees and/or Volunteers.
     
    I understand it is the express intent that the indemnity provided for in this agreement is an indemnity extended by me to indemnify and protect WARM from the consequences of WARM’s own negligence, whether that negligence is the sole or contributory cause of the resultant injury, death, or damage. I expressly agree that this agreement is intended to be as broad and inclusive as permitted by the laws of the State of Texas.

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