Qualtrics Survey | Qualtrics Experience Management

Use this form to register with The Buckeye Pantry for the 2024-2025 Academic Year.
This service is available to all Ohio State University students, staff, and faculty on the Mansfield Campus.

Student Information:

First Name:

Last Name:

OSU/Buckeyemail e-mail Address:

Birth Date:

Local Address:

City, State, Zip Code

Phone Number:

What is your housing arrangement during the semester?

On Campus - Molyet Village
Off Campus - Buckeye Village Apartments
Other Off-campus Apartments/Rental
At Home
Other

Do you have any dietary restrictions, allergies, or preferences? If yes, please describe:

No
Yes

Gender
Please select the option you most closely identify with:

What is your household size? (Include yourself, but do not include roommates. If you're currently living at home, do you live with children, spouse/partner, parents, grandparents, siblings, extended relatives, etc.)

Number of Adults:
Number of Children:
Number of Seniors:

Thank you for registering with The Buckeye Pantry.
By signing below, you are permitting Anna Wittmer, or an OSU staff member in their place, to pick up food and sign on your behalf during the Autumn 2024/Spring 2025 academic year.

Sign Here

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