Food Cupboard Intake Form [Pembroke Student ONLY] Pembroke » Services » Food Cupboard » Food Cupboard Intake Form [Pembroke Student ONLY]
"*" indicates required fields Part 1 of 2 50% The Food Cupboard is meant for those students who need it the most. Are you a current student at Algonquin College who is missing meals regularly, at risk of becoming homeless, unable to work due to mental or physical challenges, or who cannot afford life’s necessities? You may be eligible to access the Food Cupboard. The Food Cupboard is a discreet and confidential support service that provides students who are experiencing food insecurity with food and other basic necessities.Campus* Pembroke Is this your first time using the Food Cupboard?* Yes No You don't need to fill out the intake form. Please scroll down and schedule your pick-up. You don't need to fill out the intake form. Please drop-in directly. ConsentI understand that the Food Cupboard is an emergency service and I can only use the service every 30 days if needed.* I understand.I understand that this service is confidential and that my information is collected for statistical purposes.* I understand.By submitting this form I understand that the Food Cupboard is a member agency of the Ottawa Food Bank, and my information will be shared with the Ottawa Food Bank.* I understand.To continue to the intake form, please select all that apply to you:* You are in an emergency or crisis You are at risk of becoming homeless You are missing meals regularly You are not able to afford the necessities of life You are unable to work due to physical and/or mental challenges You have no other avenue to find food, and you have exhausted other sources Did you know we offer student housing support? To be connected to this service please email studenthousing@algonquincollege.com. Click [Next] to proceed to Part 2: Personal Information. Personal InformationFull Name* First Last Student Number*Student Email*NB: You MUST use your student email (@algonquinlive.com) for your order to go through. Orders received with personal emails will not be filled. Date of Birth* YYYY dash MM dash DD Are you an international student?* Yes No Do you have any children 0-3 years old?* Yes No Primary source of income:*- Please select -Primary Caregiving Benefit (CRCB)Canada Recovery Sickness Benefit (CRSB)Canada Worker Lockdown Benefit (CWLB)Canada Emergency Response Benefit (CERB)Child SupportChild Tax BenefitCPPEIEmployed (full-time)Employed (part-time)No incomeOASODSPOntario Works (OW)Private disabilityPrivate pensionProvincial disabilityScholarshipsSpouse/family supportStudent loansUndisclosedUniversal child benefitWSIBOther (specify)Other (please specify):*Housing Type:*- Please select -Emergency shelter/mission/transitionalEvacueeOwn homePrivate rentalPublic (social) housingUndisclosedUnhousedWith family/friendsYouth home/shelterOtherDon’t knowPrefer not to answer Did you know we offer student housing support? To be connected to this service please email studenthousing@algonquincollege.com.Referred By:*- Please select -Select referrerClient/friend/familyEmployment Insurance (EI)UnionsCommunity health/resource CentreMedia/news/outreachODSPOntario Works (OW)Ottawa Public Health WSIBOther Food Bank AgencyPrograms within Algonquin CollegeUndisclosedOther (specify)Don’t knowPrefer not to answerOther (please specify):*Gender Identity* Male Female Transgender None of these Prefer not to answer Disability* Yes No Don't know Prefer not to answer Racial Identity* Arab Black Chinese Filipino Indigenous Japanese Korean Latin American South Asian (e.g. East Indian, Pakistani, Sri Lankan, etc.) Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai, etc.) West Asian (e.g., Iranian, Afghan, etc.) White Other Don’t know Prefer not to answer Dietary & Allergy Restrictions:* Vegetarian No Beef Vegan Halal Kosher Diabetic Lactose intolerance Low sodium diet Gluten allergy Egg allergy Milk allergy Fruit allergy Peanut allergy Seafood allergy Sesame allergy Soy allergy Sulphite allergy Tree nuts allergy Wheat allergy Other (specify) Don’t know Prefer not to answer None that I know of Other (please specify):* Click [Submit] to submit your intake form. And, don't forget to scroll down and schedule your pick-up. Click [Submit] to submit your intake form. No appointment necessary for pick-up. Δ
