Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Gender *

Gender

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Expected Graduation Date *

MM

DD

YYYY

What is your race/ethnicity? (Check all that apply) *

Hispanic/Latino

White

Black/African-American

Asian

American Indian/Alaska Native

Native Hawaiian/Pacific Islander

Other

Do you have access to any of the following? (Check all that apply.)

Stove top

Oven

Microwave

Can opener

Running water

Refrigerator

Which of the following benefits do you or anyone in your household receive?

SNAP

WIC

TANF

Medicaid/Medicare (SoonerCare)

Free or reduced school meals

Headstart

LIHEAP (Low Income Home Energy Assistance Program)

Lifeline/SafeLink

HCVP (Tulsa Housing Authority Housing Choice Voucher Program)

Privacy Policy *

Your privacy is very important to us. The following outlines our privacy policy: • We will collect and use of personal information solely with the objective of fulfilling purposes that help the organization provide more resources to all applicants and for other compatible purposes, unless we obtain the consent of the individual concerned or as required by law. • We will only retain personal information as long as necessary for the fulfillment of those purposes. • Personal data should be relevant to the purposes for which it is to be used, and, to the extent necessary for those purposes, should be accurate, complete, and up-to-date. • We will protect personal information by reasonable security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or modification. We are committed to conducting our business in accordance with these principles in order to ensure that the confidentiality of personal information is protected and maintained.

I accept.

Terms and Conditions of Service *

I understand that some of the food distributed through the Khan Ohana Foundation Student Services program has been donated through a program sponsored by the Community Food Bank of Eastern Oklahoma and through food drives sanctioned by the Khan Ohana Foundation, and that none of the parties or groups involved in the program make any warranties as to the quality of the food or its value for any particular purposes. Some of the food distributed may have surpassed its "best by" consumption date. This date is for peak flavor and quality, and is not a purchase by or safety date. I voluntarily accept the food “as is”. By my signature below, I release Khan Ohana Foundation; participating/affiliated institution’s student government association; the participating/affiliated institution and its officers, board members, affiliates, predecessors, successors, divisions, other related entities, assigns, agents and employees, the Community Food Bank of Eastern Oklahoma; other partner agencies; and the original donor (the “released parties") from any and all claims, complaints, liabilities or obligations of any kind whatsoever, whether known or unknown arising from this program including any liability for harm (including injury or death) or losses in connection with the food or supplies I have received. I assume any risks and covenant not to sue the released parties with respect to such harm or losses. I understand that the Khan Ohana Foundation operates on limited funds and in support of others, and not as a service of any participating/affiliated institution. I will not abuse the services of the Khan Ohana Foundation Student Services program. I will only request and take the items that I reasonably expect myself, my family, and dependents to use. I understand that the privilege of participating in the Khan Ohana Foundation Student Services program may be denied to me at any time for violation of the Khan Ohana Foundation policies. Further, I agree that information provided may be shared with partner agencies for record keeping and such agencies will keep said information confidential.

By checking this box, I agree to the above terms and conditions.