Neighborhood Pantry Registration Form

Contact ID

Household ID

Pantry Location Picking Up From :

Neighborhood/Apartment Complex :

Head of Household Details:

First Name

Middle Name

Last Name

Mobile # :

Email Address:

Birthdate (MM/DD/YYYY)

Home Street :

City :

State :

Zip :

Homeless

Yes

No

Gender?

Male

Female

Chose Not to Self-Identify

Race/Ethnicity

Disabled?

Yes

No

Veteran?

Yes

No

Primary Student

ALL Requested information needs to be completed

Please list the information of the Primary Student

First Name

Middle Name

Last Name

Birthdate (MM/DD/YYYY)

School Name

Race/Ethnicity

Gender?

Male

Female

Chose Not to Self-Identify

Disabled?

Yes

No

Add more family members

Yes

No

Additional Family Members

ALL Requested information needs to be completed

Please list the Name of Each Additional Individual in your Household (ALL children and adults)

First Name

Middle Name

Last Name

Birthdate (MM/DD/YYYY)

School Name (If individual is a student)

Race/Ethnicity

Gender?

Male

Female

Chose Not to Self-Identify

Disabled?

Yes

No

Veteran?

Yes

No

Diaper size (If needed)?

Hold Harmless Agreement: By signing below, I hereby agree to indemnify, save, hold harmless, release, waive, discharge and covenant not to sue MUST Ministries, Inc., all schools located within Cobb County and Cherokee County School Districts, its officers, directors, employees, agents, and/or volunteers from any and all liability, claims, demands, actions and causes of action, and costs whatsoever arising out of or relating to any sickness, loss, damage or injury, including death, that may be sustained by me, or any member of my household, whether caused by the negligence of the releases or otherwise. I am fully aware of risks and hazards connected with participating in the program and am fully aware that there may be risks and hazards unknown to me connected with participating in the program. I hereby elect to voluntarily participate in the program, knowing that conditions may be hazardous, or may become hazardous to me and/or the individuals in my household. I voluntarily assume full responsibility for any risks of loss, property damage or personal injury, including death that may be sustained by me and/or any individual in my household, including but not limited to those associated with food allergies whether known or unknown by me or any member of my household. I understand that it is my responsibility to inspect all products received from MUST Ministries, Inc. and the Neighborhood Pantries prior to consumption to ensure product’s safety. I also understand that is my responsibility to ensure that no food allergens are consumed by any member of my household. I authorize MUST Ministries, Inc. to seek and release information concerning myself and my family to any such person or agency as MUST deems appropriate in its attempt to determine eligibility and to provide assistance to me and/or my family. I completely release MUST Ministries (which includes officers, board members, employees, agents or volunteers) and agree not to hold MUST Ministries responsible for any claims, damages or causes of action whatsoever, known or unknown, which may now or in the future arise from or in connection with any such goods or services provided to me or my family by MUST Ministries. I further agree that I fully understand this release and have had the opportunity to ask any questions about this release, and they have been answered to my satisfaction.

Participant Signature :

Enter your name

Date Signed :

As a participant in the Neighborhood Pantry:

1. I understand that it is my responsibility to notify the Neighborhood Pantry Administrator in the event I am unable to attend the regularly scheduled distribution.

(Initials)

2. I understand that I will be removed from the program after the second time that I fail to show up at the regularly scheduled distribution without prior notification to the Neighborhood Pantry Administrator

(Initials)

3. I understand that it is my responsibility to keep up with distribution dates even if I do or do not receive a reminder of the distribution. Distribution Calendars are available at every distribution.

(Initials)

4. I understand that I am not permitted to attend more than one distribution within a month and will be removed from the program should it be determined that I have done so.

(Initials)

5. I agree to notify the Neighborhood Pantry Administrator in the event that my family’s situation improves & I no longer require the assistance of the Neighborhood Pantry.

(Initials)

6. I understand that there are many families in need at my school and that I will forfeit my opportunity to participate in the program if I fail to adhere to the guidelines set forth above.

(Initials)

7. I agree to release my contact information to school staff and volunteers so that I may receive distribution reminders via email, text and/or phone call

(Initials)

8. Photographic Release: I grant and convey to MUST Ministries, Inc. all right, title and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by MUST Ministries, Inc. in connection to the services received from MUST Ministries, Inc.

(Initials)

I have read, understand and agree to all guidelines set forth above.

Signature

Enter your name

Date