Dusty's Food Pantry Form Summer 2019

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Our mission is to provide a supplemental supply of non-perishable goods to currently enrolled students that face food insecurity in order to help them maintain their focus on academics.

Dusty's Food Pantry is an imperative part of our University's endless efforts to ensure students' success and is housed out of the Office of Student Conduct and Community Engagement (STC 226, 956-326-2265).

Dusty’s Food Pantry is committed to the confidentiality of each of our students that may be facing food insecurity. The following questions are solely to keep accurate data collection of the demographics of our students as well as the performance of the Food Pantry. The information provided below will be kept confidential and used only for statistics in our annual report.

NOTE: When picking up food items, please bring reusable bags.

Full Name *

Gender *

Prefer not to Say

University ID Number *

Email *

Phone Number *

Is this your first time using Dusty's Food Pantry? *

Yes

Are you a first-generation college student? *

Yes

Are you currently employed? *

Yes

How many hours do you work per week? (If any) *

What are your living arrangements/where do you live? *

At home with parents/guardians

On Campus

Off campus (not with parents/guardians)

Are you currently a student athlete at the university? *

Yes

What type of meal plan do you have? (If any) *

Traditional

My Plan

Flex 250

Flex 50

Flex 30

None

I have access to *

Stove Top

Oven

Microwave

Can Opener

Required

Are you currently on SNAP (Supplemental Nutrition Assistance Program) benefits? *

Yes

What is the best time for you to visit Dusty's Food Pantry between 8:00am-5:00pm Monday-Friday? *

How did you hear about Dusty's Food Pantry? *

Social Media

A Friend

Faculty Member

Flyer on campus

Other

I understand that the items provided by Dusty’s Food Pantry have been donated by the community. With full knowledge of this, I, freely and voluntarily, do not hold the university (TAMIU), its offers, agents, employees, students, volunteers, and food suppliers, responsible for the quality, condition, or packaging of the food taken by Dusty’s Food Pantry. By providing my electronic signature, I acknowledge receipt of free food from Texas A&M International University and agree to the liability statement above. *

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