Student Food Assistance Request Form Name* First Last School/Program*Expected Graduation Date*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* List every one living at the above address starting with you. Note if they do not need assistance. Use a single line for each name, and please indicate their first name, last name, and date of birth for each name below. Failure to provide this information may delay your assistance. If you have any questions, don't hesitate to contact us. People residing with youFirst NameLast NameDate of Birth Weekly Delivery Day is Friday (If in campus housing, bags will be dropped off at front desk before noon.) Any week that you do not need the bag of food (out of town etc.) email us at SFAP@HelpingHandsPantry.org Occasionally we receive non-food items. Please answer the following as accurately as possible, and when these situations occur we will contact you with how you can receive these goods.Do you have a need for: Infant products (diapers, baby food etc) size, etc. Feminine hygiene (specify preference below) Personal hygiene items (soap, toothpaste etc.) Pet Food (specify number and type of pets below) Specify your preferences hereDo you live in a gated community/apt. complex?* Yes No If yes, what is your unit/apartment #?If yes, will someone be home to receive the food? Yes No If no one will be home to receive the food, please provide your gate code or specific delivery instructionsRELEASE AND WAIVER OF LIABILITY AGREEMENT I have voluntarily agreed to receive goods and services provided by HELP FOR THE HURTING, INC., dba HELPING HANDS PANTRY (hereinafter HELPING HANDS) and I understand that some, or all of the food I may receive is salvage food or may be beyond the expiration date. I understand that it is my sole responsibility to ensure that the food I receive from HELPING HANDS is fit for human consumption. In exchange for receipt of goods and services at no cost or a reduced cost, I hereby forever release HELPING HANDS and its officers, directors, employees, or volunteers from any action, demand, claim, cause of action, for bodily injury, personal injury, death, property damage, damage of any kind, whether at law or in equity or known or unknown claims, which has or might have been caused by any good or service received from HELPING HANDS and its officers, directors, employees, or volunteers. This release includes any negligent act or omission whether active or passive on the part of HELPING HANDS and its officers, directors, employees, or volunteers whether on or off the premises of HELPING HANDS. I understand that during my participation in and association with HELPING HANDS, I may be photographed, video taped, voice recorded or other electronic documentation. In exchange for free goods and services as good consideration, I agree to allow my photograph, video, or likeness whether visual or audio, to be used for any legitimate purpose by HELPING HANDS, its officers, directors, employees or volunteers. Legitimate purposes for use of my photograph, image, voice recording or other electronic documentation, include but are not limited to, promotional materials, electronic presentations, bulletin boards, power point presentations, name tags, press articles, press stories, publications or other use at the sole discretion of HELPING HANDS, its officers, directors, employees or volunteers. I hereby waive my rights pursuant to California Civil Code Section 1542, which provides as follows: “A general release does not extend to claims which the creditor does not know or suspect to exist in his or her favor at the time of executing the release, which if known by him or her must have materially affected his or her settlement with the debtor.” California Civil Code, Section 1542. This release of liability shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL. Typing your name here acts as a digital signature, signifying your acceptance of this agreement. Name*Age*CAPTCHANameThis field is for validation purposes and should be left unchanged.
