Client Registration Form

Aurora Food Pantry Registration- PLEASE PRINT	            Today’s Date:________________

Name (first):_________________________________	Name (last)_____________________________
Gender:    Male    Female    Non-binary
Family Status:  	Single	Married       Common Law    Divorced	Separated 	Widowed
Street Address:_________________________________		Postal Code:______________________
 City/Town: 	Aurora	         North Oak Ridges	       Other_____________________________________
Housing: 	Rent 		Own		Subsidized	Other___________________________  
Email:___________________________________	Telephone:_____________________________

Please PRINT in the space below the names (including your own) and birthdates of all the people in your 
household.
Name (first/ last)	Birth date (month/Day/Year)	Form of ID Presented (please specify)	Relationship
			
			
			
			
			
			
			
      
Statistical Information
Where applicable please circle the response that most applies to your situation

Languages Spoken:______________________

Referred by: 	Client or family friend 	Social Agency 	Walk-In		Other____________________

Less than 10 years in Canada?  Yes, Arrival Date: _______________

Your highest level of Education: Elementary School  High School 	College Diploma    University Degree 

Are you currently enrolled in post-secondary education? Yes    No	Is anyone in your household?  Yes 	No

Forms of Income, please check the correct boxes
Employed Full-time 		Employed Part-time 		Ontario Works Child Tax Credit 
Ontario Disability Support Program  	Canadian Pension Plan  Old Age Security 	
Employment Insurance Other 

Does more than one person work in the household?  Yes No		          

Do you or any of your family members have dietary considerations?  Yes 	No 
If yes, please list:_________________________________________________________




AURORA FOOD PANTRY:  CLIENT AGREEMENT

This form is the agreement between the Aurora Food Pantry and you, the client.  It is renewed each year.  Our staff and volunteers will treat all clients fairly and with dignity and respect.  We do our best to provide a variety of food choices from the Canada Food Guide.

Pantry Rules

	To use the Pantry you must live in Aurora or North Oak Ridges and be able to show proof of your address for all adults.  You may use: a utility bill, lease, bank statement, or other mail approved by the manager.
	You must provide identification for yourself and anyone else in your home requiring food.  This can be a birth certificate, driver’s licence, health card, passport, residency card, Indian status card, student card or landing papers. 
	You may visit the Pantry once per calendar month.  We provide enough food to last at least 5 days.
	Clients will be asked to leave for inappropriate behaviour, such as use of profane or inappropriate language, destruction of property, or verbal or physical abuse of clients, staff or volunteers.
	The Aurora Food Pantry can refuse to serve you if you do not follow these rules.

How to Use the Pantry

	Please bring your own grocery bags.
	Put your name down on the Sign In Sheet at the front desk when you arrive.
	Let the front desk volunteer know about any dietary or religious food restrictions.
	A trained volunteer will take one shopper from your family around the Pantry to collect your food.

Privacy

The personal information on this form is collected to make sure you are at the right food bank, to help us provide services, and for statistical reasons.  All personal information will be collected and stored in a safe and private manner.  The information will be accessible by other food banks in York Region. 


Consent, Release and Waiver

I, _________________________________, acknowledge that the Aurora Food Pantry (AFP) is an emergency service for residents in need of temporary assistance, and I understand that many of the goods are donated.

In signing below, I agree to release the AFP and its staff, volunteers, officers and directors from all responsibility pertaining to ANY issues related to the food or other products received.  I realize it is my responsibility to check all food/products, including best before dates and expiration dates, before use.

I also agree to the Pantry rules and consent to the collection, use and storage of my information as outlined above.  

Client signature _______________________________   Date ______________________