Food Pantry Request Form

Food Pantry Program

Students (must be enrolled in at least 1 SUSCC credit) may request food from the food pantry.
Name:*

First NameLast Name
Southern Union ID (A Number):*
If you don't have an A number, type in NA.
Cell Phone:*
Please enter a valid phone number.
Email:*
example01@mail.suscc.edu
Number of people in household:
Number in Household 18 and under:
Number in Household 60 and over:
Which campus do you attend classes?*
Dorm Room Number (if applicable):
List below any dietary restrictions or food allergies. If you are not allergic to any foods, please type in None.*
Select the items you have access to:*

StoveCooking UtensilsMicrowaveCan Opener
Please select your food preferences from the options below. All request will be filled based on availability.
Select the items you would like to request:*

Ramen NoodlesMac and CheeseCanned Chef Boyardee RavioliCanned TunaCanned ChickenCanned CornCanned Green BeansCanned Pork and BeansCanned Vienna SausageChiliSaltine CrackersCanned SoupCanned Black BeansBeanie WeeniesPeanut ButterCanned PastaCanned TomatoesCanned Pasta SauceSpaghetti NoodlesRiceRice-A-RoniMashed PotatoesPancake MixOatmealCerealGranola BarsGritsFruit CupsPop-TartsSnack CrackersPudding CupsMicrowave PopcornCan OpenerToilet PaperPaper TowelsSoapShampooConditionerToothbrushToothpasteLotionDeodorantFeminine Hygiene TamponsFeminine Hygiene Pads
Please list any special items not listed you would like to request:
Examples, Veggies, Condiments, etc.
When are you on campus and available to pick up these items (must be during normal working hours):*

AnytimeMondayTuesdayWednesdayThursdayFriday (7:15 am - 12:15 pm)
Acknowledgement of Free Food and Waiver of Liability:*

By checking this box I acknowledge receipt of free food from Southern Union State Community College Campus Food Pantry. I understand that this is a gift and not a reoccurring obligation by Southern Union or the Campus Food Pantry. I further understand and agree that by accepting this donated food I freely and voluntarily with full knowledge hold (Southern Union, its officers, agents, employees, students, volunteers, and food suppliers) harmless and in no way liable or responsible for the quality, condition, or packaging of the food.
Please verify that you are human*
Should be Empty: