Jefferson Campus Pioneer Pantry Customer Registration
Please complete the information on the form below to register for the Pioneer Pantry food bag distribution. Thank you and we look forward to serving you!
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Email *
Please provide your first and last name *
Please provide your address below. *
Are you a new or returning customer of the Pioneer Pantry? *
Do you plan to pick up your food bag on Thursday or Saturday? *
What is your date of birth? *
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Please select the number of people in your household. *
Please list any food allergies. *
Please select the gender that you identify with: *
Please select the race that best describes you (check all that apply): *
Required
Are you eligible for SNAP/TANF/SSI? (check all that apply) *
Required
What is your affiliation with Jefferson State Community College? *
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