Student Storehouse Request Form

First Name *

Last Name *

Email Address *

Your Phone Number *

What type of housing do you have? *

On Campus

Off Campus

Other Other

How many individuals are in your household? *

Please select NON-FOOD items you would like added to your Storehouse request.

Please select FOOD items you would like added to your Storehouse request.

Please select COLD WEATHER CLOTHING items you would like added to your Storehouse request.

Winter Coat

Gloves

Winter Hat

Other Other

Do you have any dietary restrictions or food allergies? *

Yes

No

Please describe: *

You will be emailed with a pick-up time. All orders can be picked up at the Dean of Students Office (2006) or the Wellbeing & Accessibility Office* (1227).

*If you would prefer to pick up your order in the Wellbeing & Accessibility Office that has an exterior back door for confidentiality purposes, we will accommodate that request. Please click below which location you prefer for your pickup location.

Where would you like to pick up the item(s)? *

Dean of Students Office

Wellbeing & Accessibility Office

Information collected will not be used to determine need.

Western Wyoming Community College is an Equal Opportunity institution, and as such, does not discriminate on the basis of race, color, national origin, sex, age, religion, disability or veteran status in admission or access to, or treatment or employment in, its educational programs or activities. For inquiries concerning Title VI, Title IX, Section 504, ADA , or to access grievance procedures, contact Amy Galley, Western Wyoming Community College, 2500 College Drive, Rock Springs, WY 82901, phone: (307) 382-1645 or Office for Civil Rights, Denver Office, US Department of Education, Cesar E Chavez Memorial Building, Suite 310, 1244 Spear Avenue Blvd., Denver, CO 80204-3582, (303) 844-5695, Fax: (303) 844-4303 or TDD (303) 844-3417 or the Wyoming Labor Standards Department, 1510 East Pershing Blvd., Cheyenne, WY 82002 (307) 777-7261.