School #33 Foodlink - Emergency Food Pantry Intake Form

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If you and your family are struggling with having enough food to eat, our new Emergency Food Pantry right here in our school is here for your needs. As part of our partnership with Foodlink, School #33 is asked to report the overall number of households, children, adults, and seniors served through the pantry every month. However, the identifying information (parent and student names, zip codes) recorded here is kept confidential and is not shared outside of the school – this is for internal record-keeping purposes only.

Feel free to contact any of our school social workers, or the direct contacts for the Food Pantry:

Mary Peoples, Parent Liaison Lindsey Feigenbaum, Community School Site Coordinator
(585) 482-9290 ext. 1013 (585) 482-9290 ext. 1220

Parent/Guardian Name *

Student(s) Name *

Which zipcode do you live in? (e.g. 14605)

How many children are in your household? *

How many seniors are in your household? (65+) *

How many adults are in your household? *

It’s important that you are able to pick-up food directly from the pantry. Please confirm who will be available to pick-up your order: *

I am able to pick-up

Someone else is picking up for me (see question below*)

I absolutely cannot pick-up and need assistance

*If someone else is picking up for you, please provide their name below:

Please provide your contact information below so we can follow-up and set an appointment! *

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