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D300 Food Pantry Family Intake Form

Si necesita este formulario en español haga clic aquí.

Please answer all questions so that we may serve you better. This information will not be shared with any other outside agency or entity other than the D300 School District and Northern Illinois Food Bank for reporting purposes. If you have a question about this form, please reach out to our registration team at registration@d300foodpantry.org.

Head of household information:

Consent and Disclaimer

Do you give consent to D300 Food Pantry to share photos taken of you and/or your children on D300 Food Pantry website, social media, or other D300 Food Pantry marketing material, without expectation of compensation?

The D300 Food Pantry and Northern Illinois Food Bank respects your information and wants to ensure it remains private. Providing information electronically can be safer than providing information on paper. Only certain staff and volunteers can log in to the system, and each person has been trained and has signed an agreement to keep your information private. We may use your personal information for a variety of reasons:

 

  • To Improve Our Programs: We may use your information to improve our programs or activities. For example, staff may look at information to review the quality of services that people receive.
  • To Do Research: We may use your information for research and analysis. Any reports produced with the data will not identify your individual information. Our staff and volunteers will only share your information with qualified persons outside of our agency.
  • To Connect You with Other Programs: At your request, we may share your personal information to see if you are eligible for other benefits or programs such as Social Security benefits or SNAP.
  • To Report Abuse, Harm or Neglect: We are required by law to report any cases of suspected abuse or neglect of children or vulnerable adults. We are also required to share information about you to law enforcement in certain cases, for example, if you cause harm to a member of our staff, another client, or if you damage our property. We may also share your personal information in case of a threat to the public, such as a terrorist attack or natural disaster.

 

By checking the box below means you have read and understand the information usage disclaimer above.

Also, by typing in your full name in the field below constitutes your approval that all the information you have entered on this form is accurate to the best of your knowledge.

 

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