FBCA Food Pantry and Assistance Application 
If your looking for food assistance and you live in Shelby county, then fill out this application. 
Sign in to Google to save your progress. Learn more
Date *
MM
/
DD
/
YYYY
First, Last and Middle Name *
Physical Address *
Marital status *
How many people in household *
Number of people ages 0-18 in your household *
Number of people ages 19-59 in your household *
Number of people ages 60+ in your household *
Do you have a referral? If so from whom?
Do you receive food stamps? If so how much? *
Mobile # (Home #) *
Have you received assistance from any other church, Ministry, or agency within the last three months? If so whom? *
Household  income of all the people in the household including SSI, SSDI, unemployment, Workmen’s Comp. and  income. *
Names of everyone who lives in the household and their ages.  *
Do you need adult diapers, size?
Clear selection
Do you need children’s size diapers? 
Clear selection
If anyone else needs to pick up for you at any time, then please print their name giving us authorization to allow them to pick up your food. *
FBCA Food and Benevolence ministry partners with several churches , social service agencies and other organizations. When you sign this agreement, we will enter your information into CharityTracker to keep track of the assistance and dates. 

Type your name below to act as your acknowledgement of receipt and agreement.
 *

Be sure to read the following paragraph and sign at the bottom. If you have questions or don’t understand,
ask your interviewer to explain.

I agree that all the information on this application is true and correct to the best of my knowledge. I understand that any attempt to give untrue or misleading information is justifiable cause to be turned down for services. I also understand that the Church and FBCA Community Ministries is not a government agency under contract to provide services to the community and that any services provided are done so as a benevolent ministry. The CCM of FBCA Community Ministries reserves the right to turn anyone down for services who gives untrue information on this application or to the interviewer; or who exhibits inappropriate behavior toward a Food Ministry volunteer or employee. The CCM of FBCA Community Ministries has my permission to check any information collected from this application or gathered by the interviewer in order to verify the need for assistance. This information and/or any services received here may be shared with other agencies or ministries who provide the same or similar assistance via telephone, fax, internet (email and/or computerized tracking programs), personal communications, etc.

Type your name below to act as your acknowledgement of receipt and agreement.
 *
FBC Alabaster food ministry hours are the 2nd and 4th  Monday from 11 AM to 1 PM. This is a first come first serve, when we run out of food boxes we will be closed for the day. You must provide proof of a Shelby County address through utility bill, lease or mortgage statement every six months in order to receive food. FBCA food ministry policy is that we are open the 2nd  and 4th  Monday of each month and you can choose ONE Monday a month to come pick up food. We need to be sure that we have enough resources for all the families in Shelby County that are in need. Please help us by following this policy. Please enter today's Date to indicate acknowledgement of this information. *
MM
/
DD
/
YYYY
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms