Fuel Pantry New Client Registration
This form is used to collect basic demographic data and assist us in identifying services that the Fuel Pantry should offer. We have been given the opportunity to apply for grants and additional funding and having accurate demographic data is crucial to successful applications.

All information provided is kept confidential and will only be used for reporting and advocacy purposes. Your name and contact information will never be shared. YOU ONLY NEED TO COMPLETE THIS FORM 1 TIME. If you have any questions about this form, please email CODFuelPantry@gmail.com.

Once you have completed this form, please head to the Fuel Pantry to shop.

Thank you.

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First and Last Name *
College of DuPage Email Address *
Phone number *
Please enter Date of Birth (Month/Date/Year). We need this information to verify your identity in our records system. *
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What is your Primary Language? *
Please check off the groups for which you identify: *
Required
Which COD campus do you attend? *
What describes your current status at College of DuPage? *
Do you receive financial aid to attend COD? *
How many individuals are in your household? *
How many of those individuals in your household (excluding you) are under the age of 18?
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How many of those individuals (excluding you) are 65 or older?
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What government assistance/benefits do you or someone in your household receive? Please check all that apply:
Do you have any of the following dietary/nutritional needs for you or anyone in your household? Please check all that apply:
Are you of Hispanic, Latino/Latina/Latinx, or of Spanish origin? *
How would you best describe yourself? *
In the past 12 months, were you ever worried your food would run out before you got money to buy more? *
Please check all that apply to you for the last 12 months: (Note: immediate household is anyone that lives in your house with you). *
Required
Which county do you live in? We use this information to send you the most relevant community resources as we learn about them. Many community organizations only serve residents of specific counties.
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How did you hear about the Fuel Pantry?
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