Emergency Pantry Application

Please complete this brief form to request services. You must live in Cedar, Clinton, Muscatine, or Scott County in Iowa.
If you have young ones and are in need of diapers, you can apply for free ones using the form below. We’ll be in touch soon after your submission.
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Contact Information
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Address
Are you homeless?*
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Additional Household Members
Please enter the following information for all of the additional individuals living in your household.
Member 2
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Member 3
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Member 4
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Member 5
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Member 6
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Member 7
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Middle Name
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Member 8
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Income
You may not apply for diapers if you are over income, but you may still apply for food.
Household Size Annual Income
1 $25,520
2 $34,480
3 $43,440
4 $52,400
5 $61,360
6 $70,320
7 $79,280
8 $88,240
Self-Declaration of Income
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Needs
Food boxes provide about 48 hours of food per person. This is a free service open to anyone who needs it. After you receive your food, if you need food again in a few days, you can come back here and request more. If you request delivery and you are not at home, we cannot leave food that requires refrigeration.
Please indicate your need*
Diapers
We cannot honor requests for specific brands of diapers, and we cannot provide pull-ups. We will include baby wipes with diaper deliveries. You can come back here to request diapers weekly if you need them.
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Transportation
Do you have transportation to pick up these items at our office?*
Other Notes