BUCKY’S FOOD PANTRY

FIRST TIME APPLICATION

Please complete the form to the best of your ability, some fields are required. Forms may be submitted via email to or submitted in person to W277 MSHA Athletic Center. The information provided from this form will only be seen by the staff responsible for the food pantry and used for internal reporting. Personal information will be kept confidential and only statistical information will be used.

General Information Date:

First Name: Last Name:

Preferred E-mail Address: E#:

Number in household: Adults Children Are you on a meal plan? Yes No

Do you have access to the following: (Check all that apply):

Stove top Oven Microwave Can Opener Running Water

Please check which of the following items you will use. Some items may not be available:

Soup / Macaroni & Cheese / Peanut Butter / Cereal/Oats
Crackers / Jelly/Jam / Ramen Noodles / Canned Vegetables
Rice / Pasta / Potatoes / Canned Meats
Beans / Granola Bars / Spaghetti Sauce / Canned Fruits
Coffee/Creamer / Tea / Water (Bottled) / Juices
Flour / Sugar / Oil/Shortening / Cake Mixes/Icing
Frozen Foods / Jell-O / Jell-O Puddings / Chips (Potato/Corn)

Baby Products

Diapers
(Indicate the size) / Food / Formula
(Indicate the kind) / Wipes

PERSONAL HYGIENE PRODUCTS:

Toothbrushes/Toothpaste / Mouthwash / Deodorants / Shampoo/Conditioner
Soap (Bar) / Body Wash / Shave Cream / Razors
Hygiene Products (Ladies)
Dietary Restrictions / Allergies:
Culturally / Religiously Important Foods:
How did you hear about Bucky’s Food Pantry?
Are there any other special needs, other than food that we can find resources for you?

Phone Number: Cell Phone Number:

Acceptance of Free Food and Waiver of Liability

By my signature I acknowledge receipt of free food from the East Tennessee State University Bucky’s Food Pantry. I understand this is a gift and not a reoccurring obligation by East Tennessee State University or Bucky’s Food Pantry. I further understand and agree that by accepting this donated food I freely and voluntarily, with full knowledge, hold harmless and in no way liable or responsible for the quality, condition or packaging of the food, Bucky’s Food Pantry, East Tennessee State University, its officers, agents, employees, students, volunteers, and food suppliers. If you have any disability that impairs your ability to pick up the food, please have a family member or friend assist you with the pick-up.

Signature: / Date:
Prepared by: / Date:
Picked up by: / Date:
Witnessed by: / Date:
No. of Bags/Boxes Issued: