D300 Food Pantry Family Intake Form

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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.

Required *

Head of household information:

Your First Name

Middle Name

Last Name

Address

City

State

Zip Code

County

Ethnicity/Race

Date of Birth

Gender

MaleFemaleOther

Phone

Current Employment Type

Do you, or does someone in your household, work for D300 School District, or a D300 contracted Employer? (Proof of employment, may be required.)

YesNo

Besides you, how many other people live in your house

List all other adults and children living in house

Please fill out first name, last name, gender (M/F), school they attend, date of birth, and race.

First and Last Name of Resident #1

Is Resident 1 Under The Age Of 18

YesNo

School Child 1 Attends

Gender of Resident #1

MaleFemaleOther

Date of Birth of Resident #1

Ethnicity/Race of Resident #1

Relationship of Resident #1

First and Last Name of Resident #2

Is Resident 2 Under The Age Of 18

YesNo

School Child 2 Attends

Gender of Resident #2

MaleFemaleOther

Date of Birth of Resident #2

Ethnicity/Race of Resident #2

Relationship of Resident #2

First and Last Name of Resident #3

Is Resident 3 Under The Age Of 18

YesNo

School Child 3 Attends

Gender of Resident #3

MaleFemaleOther

Date of Birth of Resident #3

Ethnicity/Race of Resident #3

Relationship of Resident #3

First and Last Name of Resident #4

Is Resident 4 Under The Age Of 18

YesNo

School Child 4 Attends

Gender of Resident #4

MaleFemaleOther

Date of Birth of Resident #4

Ethnicity/Race of Resident #4

Relationship of Resident #4

First and Last Name of Resident #5

Is Resident 5 Under The Age Of 18

YesNo

School Child 5 Attends

Gender of Resident #5

MaleFemaleOther

Date of Birth of Resident #5

Ethnicity/Race of Resident #5

Relationship of Resident #5

First and Last Name of Resident #6

Is Resident 6 Under The Age Of 18

YesNo

School Child 6 Attends

Gender of Resident #6

MaleFemaleOther

Ethnicity/Race of Resident #6

Date of Birth of Resident #6

Relationship of Resident #6

First and Last Name of Resident #7

Is Resident 7 Under The Age Of 18

YesNo

School Child 7 Attends

Gender of Resident #7

MaleFemaleOther

Date of Birth of Resident #7

Ethnicity/Race of Resident #7

Relationship of Resident #7

First and Last Name of Resident #8

Is Resident 8 Under The Age Of 18

YesNo

School Child 8 Attends

Gender of Resident #8

MaleFemaleOther

Date of Birth of Resident #8

Ethnicity/Race of Resident #8

Relationship of Resident #8

First and Last Name of Resident #9

Is Resident 9 Under The Age Of 18

YesNo

School Child 9 Attends

Gender of Resident #9

MaleFemaleOther

Date of Birth of Resident #9

Ethnicity/Race of Resident #9

Relationship of Resident #9

First and Last Name of Resident #10

Is Resident 10 Under The Age Of 18

YesNo

School Child 10 Attends

Gender of Resident #10

MaleFemaleOther

Date of Birth of Resident #10

Ethnicity/Race of Resident #10

Relationship of Resident #10

Household Dietary Restrictions (check all that apply)

No Gluten/WheatNo DairyNo Peanuts/Tree NutsNo PorkNo MeatNo ShellfishVegetarianVeganHalalKosherNone

Does your family receive any type of assistance? Check all that apply.

LILEAP (Low Income Energy Assistance Program)Supplemental Nutrition for Women, Infant and Children (WIC)SNAP (LINK CARD)Other (e.g. Free or Reduced Meals at School)

Consent and Disclaimer

The D300 Food Pantry may want to use images of you and/or household members that we capture during your visits on our website, social media, or other marketing material. No names would be associated with these images.

Do you give your consent?

Yes, I give consent to use images.No, I do not give consent to use images.

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.

I have read and understand:

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.

Your Electronic Signature Is Required:

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D300 Food Pantry Family Intake Form

Head of household information:

List all other adults and children living in house

Consent and Disclaimer

Donate to the D300 Food Pantry