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Food Pantry Request Form

This is a form for students who are in need of food assistance. Please complete and submit this form to receive a food package. To be eligible for food assistance this month, this form must be completed by Friday, May 10th, 2019 by  12 noon. Food boxes will be available for pick up from Wednesday, May 15 thru Friday, May 17 from 12:00 noon – 7:00 p.m. in Vista Residence Hall (ground floor) located at 2165 D Street on campus.

Your privacy is very important. We are committed to maintaining the confidentiality of those who utilize the Food Pantry. The personal information you provide is kept strictly confidential.

All participants of the food pantry program must electronic sign the liability waiver form available here (electronic signature available in the form).

After clicking Submit, you will receive an email letting you know that your request has been received.

Food boxes are intended to last one week. A standard box will include: soup (canned and/or dried), crackers, fruit cups, Mac and cheese or other prepared dinners (with pasta or rice), peanut butter, canned veggies (corn and green beans), canned beans (black, pinto, etc), canned meats (for non-vegetarians), pasta and tomato sauce, and breakfast items like oatmeal, granola bars, protein bars, and pop tarts. Vegetarian boxes will not include meat, poultry or fish. In the form below, you can let us know if there are other foods you do not or cannot eat.

Food Request Form

    (Note: If you checked "vegetarian" above, your food box will NOT include meat, poultry or fish)
  • Food Pantry selection information

    Some of the contents of your food bag will require a can opener, and/or stove or microwave to prepare your food. Can openers can be obtained from the food pantry. In addition, the following places on campus have been identified to have all of the above tools/appliances for your use: a) Barb's Place (ground floor, ACC), b) Hoover Building, c) Hanawalt House (first floor), d) Multicultural Center (in Pavillion). If you have questions or need assistance, please contact the Leo Food Pantry at leofoodpantry@laverne.edu
  • Waiver

    By checking the box below I acknowledge that I have read the liability waiver form. I understand that the waiver form is written to be as broad and inclusive as legally permitted by the State of California. I agree that if any portion is held invalid or unenforceable, I will continue to be bound by the remaining terms. I have read the waiver, and I am signing it freely. No other representations concerning the legal effect of this document.
  • Date Format: MM slash DD slash YYYY