Last Name                            First Name                               M.I.                    Today's Date

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Address                           Apt #           City               Zip Code                       Phone

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Birth Date         Age        Total in Household                Email Address                    Ethnicity

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                                                                        Please Answer Y or N
Food Stamps        SS           Disability               Unemployment                    Other

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                                                                         Household Members
Name                                          Relationship                       Birthdate                      Age

1)____________________________________________________________________________________
2)____________________________________________________________________________________
3)____________________________________________________________________________________
4)____________________________________________________________________________________
5)____________________________________________________________________________________
6)____________________________________________________________________________________
7)____________________________________________________________________________________
8)____________________________________________________________________________________
9)____________________________________________________________________________________
10)___________________________________________________________________________________

Release of Information/Applicant Attestation:
I certify that the information that I have provided is true and correct to the best of my knowledge.  I consent to the release of pertinate information contained in the spaces above to concerned Social Service Agencies or Vendors as necessary to complete the delivery of assistance to my household.
Applicant's Signature_______________________________________________________________
Interviewer's Signature______________________________________________________________

WAIVER OF LIABILITY, ASSUMPTION OF RISK, RELEASE AND INDEMNITY AGREEMENT
In consideration of receiving food from Ozark Food Pantry, Inc., the undersigned on behalf of the undersigned, the undersigned's children, heirs, and next of kin (herinafter collectively called Receipient) do hereby agree with Ozark Food Inc. (hereinafter called Food Pantry) that:
1.  Recipient will carefully examine all food prior to consuming the same to ensure that the same is appropriate for consumption.Recipient or damage to Recipient's property arising from the food obtained from Food Pantry.
2.  Recipient acknowledges that some of the food distributed by Ozark Food Pantry, Inc. is food that has been in the food distribution chain, but has not been sold and therefore has been collected from the usual food processing chain for distribution through the Food Pantry, and said food may not be of the same quality as food obtained through the normal food distribution chain.  And Recipient hereby assumes the risk of bodily injury, death, or property damage, caused by the condition of food causing the same or caused by any act or omission of Food Pantry, and it officers, agents, employees, volunteers, and officials.
3. Recipient shall indemnify and hold harmless Food Pantry and its officers, agents, employees, volunteers, and officials from any and all claims and the expenses, attorneys fees, and costs for the defense arising from the food obtained from Food Panttry.
4. Recipient shall indemnify and hold harmless Food Pantry and its officers, agents, employees, volunteers, and officials from andy and all claims and the expenses, attorneys fees, and costs for the defense thereof arising from any injury to or death of Recipient or damage to Recipient's proerty arising from the food obtained from Food Pantry.
5. This agreement shall be construed in accordance with the laws of Missouri.
     -I understand I may be prosecuted under current laws for accepting food for which I am not eligible.
     -My application may be selected on a sample basis for verification.  Should my Application be selected, I will cooperate fully in the                verification.
     -I will furnish PERMISSION SLIP, to the person I request to pick up my food.
Food received under this program is NOT to be SOLD or EXCHANGED.
 
Applicant's Signature________________________________________________ Date ______________________
 
Print Name ________________________________________________________________________

Please Print this Form and PRINT your answers Clearly. Bring it with you
                                 to the Food Pantry on your First Visit.