Food Pantry
Food Request Form
The Food Pantry is here to serve all San Jacinto College students who need food. Please know that The Food Pantry
works on the honor system. Food not picked-up on distribution date gets returned to The Food Pantry inventory.
First
Last Name
Student ID #
Male
Do you financially support other family members?
Female
If yes, please include in questions below.
Do you have children? Yes / No If yes, how many?
Yes / No
Number of adults in the household:
Email address:
Phone Number:
Average Household Income (check one):
under $12,000
$12,001-24,000
$24,001 – 36,000
$36,001 +
Current Source of Income/Resources (check all that apply)
Grants/Scholarships

Student Loans
Off Campus Job
On Campus Job
Spouse/partner works
Parental Support
If you sign-up for a package and fail to pick it up two times in a semester you may be unable to
sign-up again for the rest of the semester
The Food Pantry warrants that the following release and indemnity will apply during any and all periods in which the
student receives assorted foods from The Food Pantry. The Food Pantry warrants that the donated and purchased food
will be duly inspected by its authorized representatives upon delivery and found fit for human consumption.
It is further understood and agreed by the Food Pantry that:
1. The donated/purchased food provided by the Food Pantry is accepted by student “as is”.
2. The Food Pantry is not an emergency crisis center. The intent of this program is to offer assistant to students
with limited food resources.
3. I acknowledge that I am a currently registered student of San Jacinto College.
4. I am aware and agree that I accept this donated food freely and voluntarily. I agree to indemnify and hold
harmless the San Jacinto College Food Pantry, staff, and volunteers from any claims or judgments in regards to
the quality, packaging, and/or condition of food items. SJCFP examines contents integrity but in doing so it does
not guarantee any such admissions or claims.
Student Signature ________________________________ Date: ___________________________
For Office Use Only
Student ID Verified by _________________________________
DISTRIBUTION DATE: _________________________________
Date: ___________
NAME:
# OF ADULTS IN HOSUEHOLD:
DATE:
# OF CHILDREN IN HOUSEHOLD:
PLEASE CHECK YOUR FOOD PREFERENCES FROM THE OPTIONS LISTED BELOW.
ALL REQUESTS WILL BE FILLED BASED ON AVAILABILITY.
Category
Options
Canned fruit
Pears
Pasta
Pasta
Rice / Potatoes
Rice
Vegetables
Green Beans Carrots Tomatoes Corn Beans Spaghetti Sauce
Proteins
Canned Tuna
Stew
Breakfast
Fruit Cocktail
Peaches
Fruit Cups
Raisins
Jelly
Macaroni & Cheese
Potatoes
Chili
Cereal
Canned Chicken Canned Salmon Peanut Butter
Hash
Oatmeal
Dry Beans
Grits
Ravioli / Spaghettios
Pancake Mix
Pop Tarts
Syrup Granola / Cereal Bars
Soups
Meat
Non-Meat
Recipe starter soups (cream of chicken, mushroom or celery)
Grains
Crackers
Stuffing
Any additional comments regarding your food preferences:
The Food Pantry warrants that the following release and indemnity will apply during any and all periods in which the student
receives assorted foods from The Food Pantry. The Food Pantry warrants that the donated and purchased food will be duly
inspected by its authorized representatives upon delivery and found fit for human consumption.
It is further understood and agreed by the Food Pantry that:
1.
2.
3.
4.
The donated/purchased food provided by the Food Pantry is accepted by student “as is”.
The Food Pantry is not an emergency crisis center. The intent of this program is to offer assistant to students with limited
food resources.
I acknowledge that I am a currently registered student of San Jacinto College.
I am aware and agree that I accept this donated food freely and voluntarily. I agree to indemnify and hold harmless the San
Jacinto College Food Pantry, staff, and volunteers from any claims or judgments in regards to the quality, packaging, and/or
condition of food items. SJCFP examines contents integrity but in doing so it does not guarantee any such admissions or
claims.
Student Signature ________________________________ Date: ___________________________