College Community Connection - Student Intake Form | MVCC

First Name: Last Name: M number: Phone number: E-mail address: Term: Year: County of Residence:

Dorm Student: Yes No *Required

Returning C3 Student: Yes No *Required

Full or Part Time Student: Full-Time Part-Time *Required

Referred By: (Limit 20 Characters)

C3 Services

Food Insecurities
Child/Elder Care
Clothing
HEAP/Utilities

Housing Assistance
Health Insurance
Employment
Counseling

Transportation
Taxes
Legal_Aid

Other (please list)

Additional Services

Food Stamps (SNAP)
Temp. Assistance (TA/TANF)
Child Care Assistance

WIC
Section 8

Medicaid
SSI/SSDI

Other (please list)

Are you interested in applying for SNAP? Yes No *Required

Special Services

Food Voucher
Semester Bus Pass

As Needed Bus Pass
Meal Plan

Emergency Housing
Emergency Fund

Are you interested in using the Food Pantry? Yes No *Required

Free Food and Waiver of Liability:

By my signature I acknowledge the receipt of free food from the food pantry. I understand this is a gift and not a reoccurring obligation by the college, or food pantry. I further understand and agree that by accepting this food I freely and voluntarily with full knowledge, hold harmless and in no way liable or responsible for the quality, condition or packaging of food, college or university, its officers, employees, students, donors, volunteers, and food suppliers.
Signature(Please type your name):

Release of Information? Yes No *Required

Free Food and Waiver of Liability:

By my signature, I allow the C3 program to release my information for inter campus communication and referral.
Signature(Please type your name):