EmailMe Form - CEC Food Pantry Sign-Up

Name *

First Last

Email *

Black Hawk Student ID Number *

Total Number of People in Household *

Number of Children in Household age 0-18 *

Number of Adults in Household age 19-64 *

Number of Seniors in Household age 65+ *

Are you receiving SNAP benefits? *

Yes

No

Please check all that you identify with:

Black Hawk College will make all educational and personal decisions without regard to race, color, religion, gender, sexual orientation, marital status, national origin or ancestry, age, physical or mental disability unrelated to ability, or status as a disabled veteran or Vietnam era veteran, except as specifically exempted by law.
If you will need an accommodation based on disability (e.g. sign language interpreter, special seating) to fully participate in any Black Hawk College activity or program, please contact the Disability Services Office at 309-796-5900, CAPTEL at 309-796-5903 or video phone at 309-716-3310. Please allow sufficient time to make arrangements. No person in the United States shall, on the basis of sex, be excluded from participation in, be denied the benefits of, or be subjected to discrimination
under any education program or activity receiving Federal financial assistance. Legal Citation: Title IX of the Education Amendments of 1972, and its
implementing regulation at 34 C.F.R. Part 106 (Title IX).