Swoop's Intake Form

First Name:

Last Name:

EID:

Email:

Age:

What is your current living situation? (while attending EMU)

Live On-Campus Rent Off-Campus Own a home off-campus Live with a parent or guardian Unhoused/Experiencing Homelessness

City & State: (While attending classes)

Zip Code: (While attending classes)

What is your role at EMU?

Incoming Student ECA (Early College Alliance) Student Undergraduate Student (Freshman or Sophomore) Undergraduate Student (Junior or Senior) Transfer Student Graduate Student On-Campus Student Employee Taking time off from classes (If enrolled more than one year ago, please email swoops_pantry@emich.edu) Lecturer Professor University Staff Member (non-student, non-faculty) Recent Alumni (graduated in the past year) Alumni (1 Year+, please email swoops_pantry@emich.edu)

If you are a current student, what is your expected graduation date?

Fall 2025 Winter 2026 Summer 2026 Fall 2026 Winter 2027 Summer 2027 Fall 2027 Winter 2028 Summer 2028 Fall 2028 Winter 2029 Summer 2029 or later Not Applicable, e.g. Staff, Faculty, Alumni

What College is your current/prospective major in?

College of Health and Human Services Nursing, Social Work, Exercise Science, Sports Management, etc College of Engineering and Technology Aviation, Cybersecurity, Construction, Information Security, etc College of Arts and Sciences Psychology, Biology, Computer Science, Communications, etc College of Business Accounting, Finance, Marketing, Management, etc College of Education Elementary Education, Secondary Education, Special Education, etc Non-degree Programs Professional Development, Training, Certification, etc Undecided/Not Declared Not ApplicableFaculty, Staff, Community Members, Alumni

Do you have an EMU meal plan? Please check all that apply:

No, I do not have a meal plan Yes - I have the "Commons Anytime Meal Plan" Yes - I have the "3 Per Day Plan" Yes - I have the "2 Per Day Plan" Yes - I have the "1 Per Day Plan" Yes - I use flex dollars Yes - I have the "5 Swipes Per Week Plan"

Member(s) in household that you provide for:

Indicating you provide food for these individuals means you are responsible for purchasing or providing food for them on a regular basis. Please check all that apply.

Myself Roommate(s) Partner/significant other Child(ren) Parent(s) Sibling(s) 1 or more other family member(s)Uncles, Aunts, Cousins, Grandparents, etc.

How many people (including yourself) do you intend to feed with groceries you receive from Swoop's?

How would you describe your current employment status?

If you have more than one job, please combine your hours from all jobs.

Employed Full Time (30 hours or more per week) Employed Part Time (less than 30 hours per week) Unemployed Unable to be employed (for any reason)

How many positions/jobs do you currently hold?

What is your estimated yearly household income?

Less than $16,000 $16,000-$24,999 $25,000-$36,000 $36,001-$49,000 $50,000-$75,000 Greater than $75,000 Prefer not to answer

What forms of Financial Aid (if any) do you receive or are eligible for?

Pell Grant Federal Work Study (Awarded through FAFSA) Federal LoansSubsidized, Unsubsidized, Parent PLUS, etc State Funded Grants or Scholarships EMU-Funded Scholarship I previously have received Financial Aid I am not/never have been eligible for Financial Aid

Preferred and Primary Language:

This response is used to help the Pantry secure funding; Personal identifiers are kept confidential and don't impact your access to the Pantry in anyway.

English Spanish Mandarin Chinese Arabic Prefer not to answer

How would you best describe your race/ethnicity?

Responses help the Pantry secure funding; Personal identifiers are kept confidential and don't impact your access to the Pantry

Asian Asian-American African Black or African American Hispanic/Latino/Latina/Latin White Arab/Middle Eastern Native Hawaiian or Other Pacific Islander Native-American/American Indian/Indigenous Multi-Ethnic or Multi-Racial Prefer not to answer

Are you a parent or guardian providing care for a child/children?

Yes No Prefer not to answer

How would you best describe your Gender Identity?

Responses here help the Pantry secure funding; personal identifiers are kept confidential & don't impact your access to the Pantry

Man Woman Nonbinary/Genderfluid Trans Two-Spirit Agender Intersex Prefer not to answer

How would you best describe your Sexual Orientation?

Responses here help the Pantry secure funding; personal identifiers are kept confidential & don't impact your access to the Pantry

Heterosexual Bisexual Gay Lesbian Asexual Pansexual Prefer not to answer

Do you identify as having a disability?

Responses here help the Pantry secure funding; personal identifiers are kept confidential & don't impact your access to the Pantry

Yes No Prefer not to answer

In the past 12 months, did you experience any of the following?

• Not pay or underpay your rent or mortgage
• Have an account default or go into collections
• Not pay the full amount of a gas, oil, or electricity bill
• Borrow money from friends or family to help pay bills

Yes Yes--I have experienced one or more in the past 30 days No

In the past 12 months, did you experience any of the following?

• Get evicted from your home
• Receive a summons to appear in housing court
• Move in with other people because of financial difficulties
• Not know where you were going to sleep at night (even for one night)
• Stay at a shelter, stay in an abandoned building, a car, or any other place not meant for regular housing

Yes Yes--I have experienced one or more in the past 30 days No

Are you currently receiving any of the following public benefits? Please select all that apply:

SNAP (former food stamp program) WIC Utility Assistance TANF Housing Choice Voucher (former Section 8 program) School Meals (free or reduced meal prices for children) CHIP (children's health insurance program) Medicaid Medicare Social Security Childcare Assistance (subsidized daycare) Unemployment Insurance Earned Income Credit None of the above

Do you or anyone in your household have special dietary needs such as:

Low Salt Diabetic Lactose Intolerant Vegetarian Vegan Halal Kosher Gluten Free Pescatarian Pollotarian Other

Are there any cultural/diet specific foods that the pantry could provide to meet your needs?