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Food Pantry Request Form
1
Student Information
2
Pantry Request
Date
Date Format: MM slash DD slash YYYY
Name
*
First
Last
Student ID
*
Wiley Email Address
*
Ethnicity (Choose all that apply)
African American/Black
Asian
Caucasian
Latino
Middle Eastern
Native American
Pacific Islander
Other
Other Ethnicity
*
Dietary Restrictions
*
Allergies
*
Age
*
Gender
Female
Male
Transgender
Student Status (choose all that apply):
*
Full-Time
Part-Time
Traditional Student
Non-Traditional
Please check which of the following items you will use
Soup
Chili
Chicken
Tomato
Cream
Vegetable
Other
Other Soup
*
Ramen
Vegetable
Chicken
Shrimp
Beef
Pork
Other
Other Ramen
*
Canned Meat
Tuna
Chicken
Other
Other Canned Meat
*
Canned Vegetables
Mixed Vegetables
Peas
Green Beans
Corn
Tomatoes
Carrots
Other
Other Canned Vegetable
*
Canned Beans
Dry Boxed Meals
Beef
Chicken
Vegetarian
Other
Other Canned Bean
*
Snacks
Granola/Snack Bars
Crackers
Chips
Other
Other Snack
*
Cereal
Kid Cereal
Oatmeal / Quick Oats
Breakfast Bar
Other
Other Cereal
*
Misc.
Canned Fruit
Peanut Butter
Jelly
Macaroni and Cheese
Mashed Potato
Mix Rice
Pasta and Sauce
Please note:
We want to be able to serve as many students and staff members as possible. Therefore, we ask that you refrain from requesting items that you have left over from your prior visits. Thank you!
