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Amherst Survival Center

Amherst Survival Center

Helping Neighbors in Need

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Food Pantry Online Registration

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Thank you for registering for the Amherst Survival Food Pantry. Please fill in all requested information completely and accurately. If you have any questions, please contact pantry@amherstsurvival.org. 

Please note: Filling out this online form may be difficult on some cell phone models. We apologize for the inconvenience. If you are having trouble the form, you can 1) download the form in English, Spanish, or Mandarin and email or mail it to us (pantry@amherstsurvival.org; PO Box 9629, North Amherst, MA 01059; please allow 1-2 weeks for receipt and processing), 2) call us to complete registration over the phone (413-549-3968 x109), or 3) register in person during our open hours.

Annual Food Pantry Household Declaration Form


  • Household Information

  • Designate one person as the head of your household. This can be any of the adults. We suggest selecting the person who will most often be coming to the Food Pantry or picking up groceries.
  • If your town is not on the list above, please list it here:
  • Please include your area code.
  • In this case, "household" is defined as people living together who share income/expenses of basic living costs including buying groceries, cooking together and sharing food.
  • Please choose the amount which shows your annual income (total income earned by all household members in a year):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
  • Does ANYONE in your household receive any of these benefits? Please check all that apply.
  • Your preferred language:
  • Please list:
  • How did you hear about the ASC? Check as many as apply:
  • Please list your preferred pronoun:
  • Would you like to authorize any non-household member(s) to pick up your groceries for you?
  • Please list the individual or agency you would like to pick up your groceries on your behalf.
  • Which types of frozen protein do you prefer? Check as many as apply.
  • Do you need incontinence products?
  • Do you need menstrual products?
  • Please add information about each member of your household in this section. To start, click "Add Household Member". Please list the person designated as "head of household" first.
    Name Date of Birth Actions
       
    There are no Household Members listed.

    Maximum number of household members listed reached.

  • Please note: By authorizing another individual or agency to pick up your groceries, or selecting a coordinated delivery site, you are giving permission to the Amherst Survival Center to share your name, contact information, food pantry preferences, and any other information relevant to your distribution with the person, group or organization you have specified.

  • Please choose delivery location:
  • Please note: Individual Delivery must be arranged in advance, email pantry@amherstsurvival.org.

  • By typing my name below, I certify that all information given in this application is true and correct. By completing this form, I am agreeing to receive automated appointment confirmations via call, text message or email.  By requesting grocery delivery now or in the future, I authorize the Amherst Survival Center to share my name, contact information and dietary preferences with volunteers and relevant delivery partners.

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We are open:

COMMUNITY CENTER & MEALS:
M 12-3
T 12-3
W CLOSED
TH 12-3
F 12-3

PANTRY:
M 12-3
T 12-3
W CLOSED
TH 12-7
F 12-3
S 3rd Saturday/month

Address:

P.O. Box 9629
138 Sunderland Rd.
North Amherst, MA 01059

Ph: 413-549-3968  amherstsurvival@amherstsurvival.org

We are on the PVTA bus route:

PVTA Bus 33 schedule

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