Food Hamper Application

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Food Hamper Application
Muslim Aid of Saskatchewan (MAS) in partnership with the Muslim Food Bank and Community Services Society (MFBCS) ("Societies") operates a local Muslim Food Bank serving Regina residents who have dietary restrictions (Halal, Vegetarian) & are in need of support.

IMPORTANT:
- All the information provided in this form helps us assess eligibility. This Food Hamper form is for those struggling financially and those with low income status (See Low Income Cut Off chart )
- Please ONLY FILL OUT THIS FORM ONCE for all members of the same household. You will receive a copy of your completed form via email immediately after submitting.
- If an application is not complete we will be in touch for further information to determine eligibility.
- DEADLINE TO SUBMIT to give enough time to be considered for the next food hamper distribution is: first of every month (eg. June 1st is the first of the month, Sept 1st is the first of the month, etc.)
  1. If submit after the 1st of the month, no guarantee that your application will be reviewed in time for that month's food hamper distribution.
  2. Please note: food hamper distribution day is the 2nd Saturday of every month and only available for those registered with the Societies - Muslim Aid of Saskatchewan (MAS) and Muslim Food Bank & Community Services Society.
  3. MAS will contact you before the next food hamper distribution regarding the status of your application.
If you have any questions or concerns, please email us at: foodbank@muslimaidsk.ca
Are you in need of emergency food hamper?*

YesNo
If In Need Of Emergency Food Hamper:

IMMEDIATELY CALL Muslim Food Bank (our partner organization) +1 236-979-5068

State your:
- Province
- Full name
- Request Emergency Food Hamper
ANY OTHER EMERGENCY DIAL 911
Please explain emergency*
MAS Membership Number
Leave blank if you do not have one
Which dietary restriction do you have? (select one)*
If other, please explain*
Do you or any members of your household have any allergies? (Please include details)*
If no allergies, please type "N/A"
Do you receive any assistance from the government OR any institution?*

YesNo
What is the name(s) of the organization(s)/ Government that is providing you with assistance?*
How often do you receive the assistance?*

Yearly6 monthsMonthlyBi-weeklyWeeklyOther
What kind of assistance do you receive?*

FinancialFoodOther
What is the approximate value of the assistance?*
Anything else you would like to share with us about your situation?*
If there is nothing more to share, type "No"

Name*

First NameLast Name
Gender*
Date of Birth*

YearMonthDay
Date
Email*

Confirmation EmailRe-enter the same email
Phone Number*
Please enter a valid phone number.
Whatsapp # if different from cellphone
Please enter a valid phone number.
Home Address*

Street Address

Apartment, suite, etc

CityProvince

Postal Code
Home Owner or Renter?*

OwnerRenter
Status in Canada*
Specify Status in Canada*
Country of Origin*
Date Arrived to Canada*

YearMonthDay
Date
Today's Date

YearMonthDay
Date
Number of Days
Calculation
Country Arrived From*
Province First Landed*
English Level (select one)*

(A) Beginner(B) Intermediate(C) Advanced
Languages Spoken OTHER THAN ENGLISH (select all that apply)*

ArabicBengaliFrenchSomaliUrduYorubaOther
A- Photo ID (Government) (Eg. passport, drivers license, PR, etc.)*

ID must include: photo, name, date of birth (Eg. driver's license, PR, passport)
Cancelof
B- Upload your last 3 months of bank statements*

Must provide 3 full months. Screenshots of online banking are acceptable but must be complete. All sources of income must be reflected on the bank statements.
Cancelof
C- Upload Notice of Assessment (last tax year) if have lived in Canada for more than 1 year*

Cancelof
D- Upload your rental / lease agreement (OR if own, upload property tax/ mortgage statement)*

Cancelof
Are you currently enrolled as a student? (select all that apply)*

UndergradMastersPhDNo, I'm not a student.
E- Upload your Study Permit (only if international student!)*

Cancelof
Do you or any members of your household receive payments from SAID (Saskatchewan Assured Income for Disability)?*
Are you personally on SAID (Saskatchewan Assured Income for Disability)?*
Marital Status*
Spouse Information
Spouse's Name*

First NameLast Name
Spouse's Date of Birth*

YearMonthDay
Date
A- Spouse's Photo ID Card (Government) (Eg. passport, drivers license, PR, etc.)*

ID must include: photo, name, date of birth (Eg. driver's license, PR, passport)
Cancelof
B- Upload your spouse's bank statements for the last 3 months. If they share a joint account with you, re-attach the bank statements for the joint account.*

Cancelof
C- Upload your spouse's Notice of Assessment (taxes) if have lived in Canada for more than 1 year*

Cancelof
Is your spouse on SAID (Saskatchewan Assured Income for Disability)*

Number of People Living with You (Everyone else but yourself and your spouse)*
(1) Name*

First NameLast Name
(1) Relationship to You*
(1) Specify Relationship to You*
(1) Date of Birth*

YearMonthDay
Date
(1) Photo ID (Government) (Eg. passport, drivers license, PR, etc.)*

Cancelof
(1) Is this individual on SAID (Saskatchewan Assured Income for Disability)*
(2) Name*

First NameLast Name
(2) Relationship to You*
(2) Specify Relationship to You*
(2) Date of Birth*

YearMonthDay
Date
(2) Photo ID (Government) (Eg. passport, drivers license, PR, etc.)*

Cancelof
(2) Is this individual on SAID (Saskatchewan Assured Income for Disability)*
(3) Name*

First NameLast Name
(3) Relationship to You*
(3) Specify Relationship to You*
(3) Date of Birth*

YearMonthDay
Date
(3) Photo ID (Government) (Eg. passport, drivers license, PR, etc.)*

Cancelof
(3) Is this individual on SAID (Saskatchewan Assured Income for Disability)*
(4) Name*

First NameLast Name
(4) Relationship to You*
(4) Specify Relationship to You*
(4) Date of Birth*

YearMonthDay
Date
(4) Photo ID (Government) (Eg. passport, drivers license, PR, etc.)*

Cancelof
(4) Is this individual on SAID (Saskatchewan Assured Income for Disability)*
(5-10) List all other dependents & include the info required below box.*
Please list all the following for each additional dependent: (A) Full Name (B) Date of Birth (YYYY-MM-DD) (C) Relationship to you
(5-10) Government Photo ID (attach all additional dependent's here)*

Please upload all additional dependents' photo ID
Cancelof

Monthly Income

Please enter the monthly amounts for your household below. If any field is not applicable, please enter 0.
Monthly Income*
Saskatchewan Income Support (SIS) / Immigration*
SAID*
Child Tax Benefit*
Other income*
Monthly Expenses

Please enter the monthly amounts for your household below. If any field is not applicable, please enter 0.
Rent/ Mortgage*
Utility Bills*
Internet & Phone*
Food & Groceries*
Medical Expenses*
Car Payment & Insurance*
Gas*
Public Transportation*
School Tuition*
Monthly Debt Payments/ Other expenses*
Savings

Please enter the TOTAL amounts for your household below. If any field is not applicable, please enter 0.
Balance in Bank*
Savings - TFSA*
Savings - RESP*
Savings - RRSP*
Cash at Home/ Other Asset(s)*

Is there anything else you would like to add/ share with us?*

YesNo
Share your thoughts here*

How did you hear about MAS Food Bank?*

Social media (IG, Facebook, Whatsapp, Twitter)Flyers, posters & any other marketing materialsReferral from Muslim OrganizationReferral from Community MemberOther

Food Bank Liability Release

Muslim Aid of Saskatchewan (MAS) and it's partner Muslim Food Bank & Community Services Society (MFBCS) ("Societies") are not responsible for quality or quantity of food given out. We only pass on upon request what is received as donation. The Societies do not guarantee any specific quantity or availability of any specific food item. Clients receiving any item from the Societies are themselves responsible to check the product and sustainability for use. If they are in doubt, they must not use the food and discard it. Use of any food item is solely on client's personal discretion. Checking for allergy and avoiding any specific food is solely client's responsibility. The Societies do not take any liability whatsoever in this regard.

The ASPIRE Casework is a voluntary support provided by the Societies for all food bank clients. ASPIRE aims to empower families who are in need by redirecting and connecting them with resources that are available in their local community. The goal is to help them achieve self-reliance and independence. As a participant of the ASPIRE program I agree to not take any legal action against the Societies or its volunteers and staff for any services or advice provided.

By completing this form, the client agrees to accept help and support from the Societies on these terms and completely and unconditionally indemnify them in all respects from any liability.

Privacy, Confidentiality

I agree and consent to provide the Societies access to my personal private information such as my bank statements, rental agreements, notices of assessment (taxes), proofs of work and/or other personal information that may be sensitive or confidential in nature.

I also agree and consent to provide the Societies access to the personal information of individuals residing in my household who are over the age of 18. This information includes their bank statements, rental agreements, notices of assessment (taxes), proofs of work and/or other personal information that may be sensitive or confidential in nature.

I certify that I have the permission of said individuals to act as their representative during the completion of this application.

Liability Release

I hereby release the Societies from any liability and agree to indemnify it and hold harmless its employees, volunteers, representatives and agents for any personal injuries or loss however caused, Loss or damage to property arising from using these services / activities of the Societies or at any events organized by them. I also grant and convey to the Societies all right, title and interests in any and all photographs, images, video or audio recordings of me or my likeness or voice made by the Societies as a recipient of the Societies services. I, on behalf of myself and my household members, agree to comply with the rules and regulations set by the Societies and the safety provisions established for the mentioned activity.

I hereby certify that the above statements filled out in the form are true and correct to the best of my knowledge.
Terms and Conditions*

I ACCEPT all terms and conditions.I DON'T accept all terms and conditions.
Signature*

Clear
Should be Empty:

MAS aims to offer support with food and capacity-building programs to those who are in need of assistance.

“Serving Community with Excellence”

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Food Hamper Application

Food Hamper Application

Spouse Information

Monthly Income

Monthly Expenses

Savings

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