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.
General Information
Demographic information (i.e. ethnicity, gender, and whether you are a student or staff/faculty member)
First Name
Your answer
Last Name
Your answer
Ethnicity
Gender
Student ID Number
Your answer
E-mail Address
Your answer
Date of Birth
MM
/
DD
/
YYYY
Student, Staff, or Faculty Member?
If you are a student, please complete the Academic Information section below:
Classification
Are you a first generation college student?
What college are you in?
(e.g. Arts and Sciences, Business, Technology)
Your answer
Are you a full-time student?
Are you an international student?
Household Information
How many hours a week do you work, if any?
Your answer
Are you active military or a veteran?
Your answer
What kind of housing do you currently have?
How many dependents do you have, if any?
Your answer
If you answered yes to the previous question, please list ages of your dependents
Your answer
Do you have a meal plan at the University?
If you answered yes to the previous question, which meal plan do you have?
Your answer
What county do you live in?
Please answer with your county of permanent residence
Your answer
How many people in your household are employed?
Your answer
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.
Your answer
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