Gorilla Assistance Pantry - First Time Application
This form is for users who are using the Gorilla Assistance Pantry for the first time. Information provided will be used only by GAP. Personal information will be kept confidential. Only statistical information will be used.
Demographic information (i.e. ethnicity, gender, and whether you are a student or staff/faculty member)
Prefer not to respond
Student ID Number
Date of Birth
Student, Staff, or Faculty Member?
If you are a student, please complete the Academic Information section below:
Are you a first generation college student?
What college are you in?
(e.g. Arts and Sciences, Business, Technology)
Are you a full-time student?
Are you an international student?
How many hours a week do you work, if any?
Are you active military or a veteran?
What kind of housing do you currently have?
How many dependents do you have, if any?
If you answered yes to the previous question, please list ages of your dependents
Do you have a meal plan at the University?
If you answered yes to the previous question, which meal plan do you have?
What county do you live in?
Please answer with your county of permanent residence
How many people in your household are employed?
Are you currently on SNAP* benefits?
*Supplemental Nutrition Assistance Program
Acceptance of Free Food and Waiver of Liability
By my signature, I acknowledge receipt of free food from the Pittsburg State University Gorilla Assistance Pantry. I understand and agree that by accepting this donated food I freely and voluntarily, with full knowledge, hold harmless and in no way liable or responsible for the quality, condition, or packaging of the food, Pittsburg State University, its officers, agents, employees, students, volunteers, and food suppliers.
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