First Time Visitor Form NOTE: The following information will be used only by Feed U Food Pantry management for agency reports and metrics. Your identity will remain confidential. Step 1 of 2 50% Household Last Name* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please Note:Financial Information is collected solely due to our partnership with the Utah Food Bank and their records. This will not be used in a discriminatory fashion in regard to access to the pantry. There are no financial checks or restrictions to access the pantry, all are welcome. Total Gross Monthly Income*(Estimated) Total Gross Monthly Expenses*(Estimated) Total NET Monthly Income*(Estimated) Primary Phone(e.g. xxx-xxx-xxxx)Primary Email Enter Email Confirm Email Special Needs / Additional InformationPrimary Household Ethnicity* American Indian / Alaska Native Asian Black / African American Native Hawaiian / Pacific Islander White Prefer not to disclose Household Type* Single Single Mother / Father Two Parents / Child Couple Campus Location* Main Campus How long do you expect to need food assistance?* This time only 1 month 2-5 months 6+ months Current Sources of Income*(Check all that apply) Grants / Scholarships Family Support Student Loans Off-Campus Job On-Campus Job Other If other sources of income, please specify* Reason for Need of Food Assistance*(Check all that apply) Unemployed Insufficient / Low Income Illness / Disability Unexpected Expenses Other If other reason, please specify* How did you hear about the Feed U Pantry? Word of Mouth Social Media Internet Flyer Newspaper Please read and sign the following:*I understand that the food from University of Utah Feed U Pantry may only be distributed to a current University of Utah student for themselves and their dependents (spouse and children under the age of 19). I also understand that the University of Utah Feed U Pantry has been donated from various on-campus and off-campus partners, and that none of the parties or groups involved in the program make any warranties as to the quality of the food or its value for any particular purposes. Some of the food distributed at the University of Utah Feed U Pantry has surpassed its "Best by" consumption date. This date is for peak flavor and quality, and is not a purchase by or safety date. I and my family release the University of Utah and its off-campus partners from any and all responsibility concerning the quality and safety of the University of Utah FEED U Pantry. I understand that University of Utah Feed U Pantry operates on limited funds and in support of others, and not as a service of the University of Utah. I will not abuse the services of the University of Utah Feed U Pantry. I will only request and take the items I reasonably expect myself and/or my dependents to use. Head of Household InformationuNID*(U of U Student ID - e.g. u0123456) Name* First Last Gender* Male Female Prefer not to disclose Marital Status* Single Married Couple Divorced / Separated Hispanic / Latino - Non-Hispanic* Hispanic / Latino Non-Hispanic Primary Ethnicity* American Indian / Alaska Native Asian Black / African American Native Hawaiian / Pacific Islander White Prefer not to disclose Student Status* Full-time Student Part-time Student Staff member Faculty member Current College Level* Freshman Sophmore Junior Senior Graduate Alum PhoneEmail Enter Email Confirm Email Education Completed Currently Employed? Yes No Started a Job (last 30 days) Yes No Income Increased (last 30 days) Yes No Currently receiving the following benefits(Check all that apply.) Health Insurance Food Stamp Eligibility WIC CFSP Please check all that apply Migrant Worker Immigrant / Non-Refugee Veteran Handicapped Disabled Mental Illness HIV / AIDS Abuse Victim Substance Abuse Untitled Δ
