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Quick Sign-UpOpen

Neighbor is in line now — name & household size only. ~30 seconds.

Full ApplicationYou are here

First-time registration — full address, household & signed release. 5–10 min.

Neighbor Registration

Food Pantry Required Information

Please complete this form to register as a food pantry neighbor. Your information is kept confidential and used only to serve you and report aggregate data to our funding partners.

Confidentiality Notice

All information you provide on this form is strictly confidential. True Word Ministries, dba We Care Community Center, dba We Care Food Pantry, does not share, sell, or disclose your personal information to outside parties. Your details are used only to serve you and for numerical (aggregate) reporting purposes to our funding partners — never in a way that identifies you individually.

Neighbor Information

First Name *Middle InitialLast Name *Date of Birth *Address *Apt / UnitCounty *City *State *ZIP *Email AddressTelephone Number *Secondary TelephoneWhose Number? (Secondary)

Preferred Communication

TextCallEmail

Demographic Information

Gender Identity *Race or Ethnicity *

Household Information

How many in household (not including yourself)? *

#	Name *	Date of Birth *	Age (auto)
1
2
3
4
5
6
7
8
9
10

Are you currently picking up food each month?

YesNo

Proxy (person approved to pick up when you can't)

If someone else may pick up food on your behalf, provide their information below.

Proxy NameProxy PhoneProxy AddressProxy CityProxy StateProxy ZIP

Liability Release

I, ____________________________, am a receiver of donated food from We Care Food Pantry, an outreach ministry of True Word Ministries, a 501(c)(3) non Profit, with pickup from 500 North Jackson Ave., Quitman, MS. By signing this form, I agree for myself, my children, and any household members who receive or use the donated food or goods from True Word Ministries, a 501(c)(3) non Profit, that they are:

Not responsible for any problems, harm, or losses related to the donated food or goods.
Protected from any claims, demands, or responsibilities connected to my receiving the donated food or goods.
Not making any promises or guarantees about the donated food.
Not responsible for any injuries or other harm that may happen while I am at the pickup location at 500 North Jackson Avenue, Quitman, MS.
Not holding any directors, trustees, board members, volunteers, ministry staff, officers, or the ministry itself responsible for any harm related to the donated food or goods, or for any injury that may happen at the pickup location, including claims involving me, my children, or household members.

By signing this agreement, I confirm that I have read this form, had it read to me, or had it fully explained to me. This agreement stays in effect for as long as I, my children, or my household members receive or use food or goods from We Care Food Pantry. I understand that my electronic signature below is just as valid and binding as my handwritten signature. This Liability Release applies to True Word Ministries, Inc., doing business as We Care Food Pantry and We Care Community Center.

I have read, or had read to me, the Liability Release above, and I agree to its terms.I confirm that I had the opportunity to ask questions about this Liability Release before signing it.

Signature

By typing your full name below, you confirm the information provided is accurate to the best of your knowledge.

Signature (type full name) *Date (type the date) *

I confirm that I am completing this application myself, either on paper or online.I, name listed on application, hereby give my permission to True Word Ministries to fill my form for me electronically. This form is being filed by True Word Ministries with my permission given by telephone or in person.Do not check the box if you are filing yourself.

Hold on — you must check both confirmation boxes in the Liability Release before you can sign and submit this form.