2019 Crystal Lake Food Pantry Application - Solicitud Last Name / Apellido

First / Nombre

Middle

Address / Direccion

Phone / Telefono #

Home

or

Cell

City, State, Zip Code / Cuidad, Estado, Codio Postal

Email Address / dirección de correo electrónico

Birthdate / Fecha de Nacimiento

Names of Other People in Household / Nombres de Otro Personas en Su Familia

Relationship / Parentesco

Birthdates / Fecha de Nacimiento

1 2 3 4 5 6 7 Are there other individuals or families that you know of who are in need of food assistance but do not come to the food pantry? Y / N Is there any other type of help besides food assistance that you need? (Health, Job, Benefits, etc.)_____________________________

I hereby state the information above is true and factual. This information is confidential between the person giving the information and the Crystal Lake Food Pantry. I understand the food provided to the Crystal Lake Pantry is donated and I release from all liability and hold harmless the Crystal Lake Food Pantry, its suppliers and volunteers. Retificacion: Yo, el que firma abajo, afirma que esta informacion es real y verdadera acerca de mi familia. Esta informacion por la major parte es privada entre la persona que da la informacion y la que guarda los archivos. Yo endiendo que la comida proporcionada por la despensa de comida es donada; y yo libro toda responsabilidad y danos a todo el personal, distriburidores, y voluntarios de la dispensa de comida de Crystal Lake. Signature of Applicant

Date

Firma de Solicitante

Fecha

FOR OFFICE USE ONLY

Interviewed By/Date_________________

Proof of current address ________________

Need POA for _____________________

Entered in computer by:_________________________________ Date New Client

1X

2019 update

__________________________ Client #