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Hamper Request Form for First-Time Users
Hamper Request Form (First-Time)
Name:
*
Student ID:
*
Where would you like to get the hamper?
City Centre Campus
Alberta College Campus
Birthdate:
*
Age:
*
Gender Identity:
*
Male
Female
Non-Binary
Transgender
Other
Prefer not to say
Marital Status:
*
Single
Married
Common-Law
Divorced
Separated
Widowed
Prefer not to say
Email Address:
*
Phone Number:
*
How did you hear about us?
*
MacEwan University
Friend/Family
Mental Health Support
Other Food Bank Program
Other MacEwan Student
Wellness and Psychological Services
No Referral
Other
Do you identify as:
*
Indigenous
Metis
Inuit
Not Applicable
Self Identify As:
*
Full-time Student
Part-Time Student
International Student
In Canada 10 Years or Less
Prefer not to say
Other
None
Do you have any dependants?
*
Yes
No
How many dependants do you have?
What is your relationship with your dependant?
What is the age of your dependants?
Income Information:
*
Part-Time Employment
Full-Time Employment
Scholarships/Bursiaries
Disability Assistance (AISH or alternate)
Employment Insurance (EI)
Partner is Employed
Social Assistance (Alberta Works or alternate)
No Income
Other
Prefer not to say
Dietary Consideration:
*
No Dietary Restrictions
Dairy Allergy
Egg Allergy
Gluten Allergy
Peanut Allergy
Tree Nut Allergy
Legume/Soy Allergy
Seafood Allergy
Halal
No Pork
Vegetarian
Vegan
Other
Please Specify:
Reason for your Visit?
*
Benefit/Social Assistance Changes
Benefit/Social Assistance Delays
Debt
Delayed Wages
High Dependant Care Costs
High Living Costs (rent/bills)
Homeless
Low Wages/Not Enough Hours
Ongoing Need
Relocation (Immigration/Moving)
Sickness/Medical Expenses
Unemployed - Child/Dependant Care
Unemployed - Course Load too High
Unemployed - International Student
Unemployed - Recently Lost Job
Unexpected Expense
Unexpected Housing Expense
Other
Please Specify:
Hygiene Items Required?
*
Yes
No
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