Once you have read and agree to follow the guidelines outlined, please sign electronically at the Client Attendant’s desk.
We will also verify and update your household information at this time. Please be patient during this process.
If you have any questions or would like the forms to be read aloud, please see a volunteer or staff of The Open Door for assistance. Thank you
At The Open Door, we are committed to providing professional, courteous, and caring assistance that respects and appreciates differences related to race, ethnicity, national origin, gender, sexual orientation, religion, personal values, age, disability, and economic or veteran status. What you can expect from The Open Door:
• A welcoming and safe environment where everyone is treated with dignity, respect, and kindness by volunteers and staff.
• The information you provide to remain confidential and not be shared with any other organizations. You may request to review your records at any time.
• All questions to be answered in an honest and timely manner, and access to additional resources as needed.
• Phone messages be returned within two business days.
• Access to the best quality food available each day. We ask for your patience and understanding as our food inventory changes daily and depends greatly on what is donated from local grocery store partners each morning. What you agree to as a client of The Open Door:
• Treat other clients, staff, and volunteers of The Open Door with respect, dignity, and kindness. Raised voices, profane or vulgar language, and inappropriate behavior will be addressed.
• Share requested information about your household and current situation.
• Let volunteers or staff know if you have concerns or suggestions about the service you receive. We want to work together to make sure any issues or areas of improvement are heard.
• Arrive at The Open Door appointments on time and free from the influence of any mood-altering substances,
• Not to sell or offer for sale any food or other household items received from The Open Door (this includes food grown in gardens owned by The Open Door).
The Open Door and its Clients share responsibility in ensuring a safe, welcoming environment for all seeking service or working at The Open Door. If an individual is asked to leave The Open Door premises for any reason, alternative arrangements will be made by The Open Door to ensure all clients continue to receive needed food support.
Grievance Procedure If you feel your rights have not been respected or you have not received fair treatment or proper services from The Open Door, you have the right to file a complaint or appeal. We encourage you to make a complaint by completing our formal complaint form.
This can be filed in writing and mailed to:
The Open Door, Attn: Director of Client Services, 3910 Rahn Rd, Eagan, MN 55122.
By signing below, I acknowledge that I have read or a worker has explained my rights and responsibilities and I agree to follow these guidelines.
Client Signature:_________________________________ Date:_____________________
(Name of Food Shelf or Distribution Site) Name: ________________________________________________________________________
I am eligible to receive TEFAP commodity food because I am in Minnesota and because my household income is 300% or less of the Federal Poverty Guidelines. Eligibility is granted to all persons in situations of emergency and distress due to disasters.
I am also eligible if I receive or participate in the following services and programs: OPTIONAL: Check the program(s) in which you participate:
_____ MFIP – Minnesota Family Investment Program
_____ Child Care Assistance
_____ GA – General Assistance
_____ Head Start
_____ SNAP – Supplemental Nutritional Assistance Program
_____ Section 8
_____ NAPS – Nutritional Assistance Program for Seniors
_____ Public Housing
_____ WIC – Women, Infants, and Children
_____ Energy Assistance
_____ Free and reduced breakfast and lunch
_____ Weatherization Income Eligibility: (300% of Federal Poverty Guidelines)
Family size Annual Income
One $0 – $38,640
Two $38,641 – $52,260
Three $52,261 – $65,880
Four $65,881 – $79,500
Five $79,501 – $93,120
Six $93,121 – $106,740
Seven $106,741 – $120,360
Eight $120,361 – $133,980
Add $4,540 of allowable income for each additional family member.
Data Privacy Notice/Tennessen Warning
You have rights under the Minnesota Government Data Practices Act. This Act protects your privacy. We are asking for information so we can: tell you apart from other persons with a similar name and decide how to serve you best. Generally, you are not required to give us the information. However, without it, we can’t report accurate statistics which affects funding. The law allows us to share your information (the number of children, adults, and seniors in your household and the number of pounds of food received) with staff from the Department of Human Services, Hunger Solutions Minnesota, and your regional food bank. You also have the right to copies of information we have about you. If you do not understand the information, it may be explained to you. If you do not think the information is accurate or complete, please correct it with the food shelf staff. I understand that this data privacy notice will expire one (1) year after I have signed it
Number of people in household:
_____ Children ages 0-17
_____ Adults ages 18-64
_____ Seniors ages 65+
Proxy Permission for someone else to pick up my food:
If it’s hard for you to get food from the food shelf, you have the option to select someone else to pick up your food.
I give permission to:
(name) to pick up my food
(name) to pick up my food
I understand I have the right to:
• Change who I choose to pick up my food. I will need to fill out a new form for any changes.
• Let the food shelf staff know if I want to cancel my permission.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA
programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the FederalRelay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: How to File a Complaint, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form.
To request a copy of the complaint form, call (866) 632-9992. Submit
your completed form or letter to USDA by:
(1). mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: (202) 690-7442; or
(3) email: firstname.lastname@example.org.
This institution is an equal opportunity provider.