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

Today's Date:
Month
Day
Year
Household Information
Head of Household*
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.
First Last
Your date of birth
Month
Day
Year
Email
Your physical street address (no PO Box):*
Town:*
Your town
If your town is not on the list above, please list it here:
Zip Code
Phone
Please include your area code.
How many people (including you) live in your household?*
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.
Household Income*
Please choose the amount which shows your annual income (total income earned by all household members in a year):
- $0-$19,800
- $19,801-$33,975
- $33,976-52,750
- $52,751+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$22,600
- $22,601-$37,650
- $37,651-$45,775
- $45,775-$60,250
- 60,251+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$25,450
- $25,451-$42,350
- $42,351-$57,575
- $57,575-$67,800
- $67,801+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$28,250
- $28,251-$47,050
- $47,051-$69,375
- $69,375-$75,300
- $75,301+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$30,550
- $30,551-$50,850
- $50,851-$77,600
- $77,601-$81,175
- $81,175+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$32,800
- $32,801-$54,600
- $54,601-$87,350
- $87,351-$92,975
- $92,975+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$35,050
- $35,051-$58,350
- $58,351-$93,400
- $93,401-$104,775
- $104,775+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$37,300
- $37,301-$62,150
- $62,151-$99,400
- $99,401-$116,575
- $116,575+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$39,550
- $39,551-$65,850
- $65,851-$92,750
- $92,751-$128,375
- $128,375+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$41,800
- $41,801-$69,600
- $69,601-$98,050
- $98,051-$140,175
- $140,175+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$44,100
- $44,101-$73,400
- $73,401-$103,350
- $103,351-$151,975
- $151,975+
Household Income*
Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household):
- $0-$46,300
- $46,301-$77,200
- $77,201-$108,650
- $108,651-$163,775
- $163,775+
Benefits*
Does ANYONE in your household receive any of these benefits? Please check all that apply.
- WIC
- VetAid
- MA Health/Medicaid
- TANF
- Fuel Assistance
- SSI
- Head Start
- SNAP (Food Stamps)
- AFDC
- No Benefits
- Senior Mobile Nutrition Program
Gender*
- Female/Woman
- Non-Binary
- Male/Man
- Prefer Not to Identify
Race*
- American Indian
- Black/ African
- White/ Caucasian
- Native Hawaiian
- Black/ African American
- Native Alaskan
- South Asian/ Indian
- Black/ Cape Verdean
- Other
- East Asian/ Pacific Islander
- Black/ Caribbean Islander
- Prefer Not to Identify
Ethnicity*
- Latino/a/x or Hispanic
- Not Latino/a/x or Hispanic
Preferred language*
preferred language*
Your preferred language:
Are you experiencing homelessness?*
- Yes
- No
Are you a veteran?*
- Yes
- No
Are you disabled?*
- Yes
- No
Diet*
- No special dietary needs
- Dairy Free
- Gluten Free
- Nut Free
- Vegetarian
Other dietary/special requests
Please list:
Heard about ASC
How did you hear about the ASC? Check as many as apply:
- Police or Fire Department
- Bus Driver
- Bus Advertisement
- Neighbor
- Stranger
- Newspaper
- Internet
- Brochure
- Latinx Outreach Project
- Other
- Family
- Friend
- School or College
- Doctor
- Health and Human Services Professsional
- Word of Mouth
- I’ve Been Coming for a Long Time
Pronouns*
- She/Her
- He/Him
- They/Them
- Other
Individual/Agency*
Please list your preferred pronoun:
Are you a student in an area college?*
- not a student
- UMass Amherst
- Amherst
- GCC
- Hampshire
- Mount Holyoke
- out of area college student
- STCC
- Westfield State
- HCC
- Smith
Pick up authorization
Would you like to authorize any non-household member(s) to pick up your groceries for you?
Individual/Agency*
Please list the individual or agency you would like to pick up your groceries on your behalf.
Do you have transportation to the ASC under normal circumstances?
- Yes
- No
Do you have transportation to the ASC currently?
- Yes
- No
Do you need delivery?*
Frozen Protein
Which types of frozen protein do you prefer? Check as many as apply.
- Chicken
- Turkey
- Beef
- Pork
- Fish
- Vegetarian
Incontinence products?
Do you need incontinence products?
- Bed pads
- Adult briefs
Adult briefs gender
Adult briefs size
Menstrual products?
Do you need menstrual products?
- Tampons
- Pads
How many cats live in your household?
How many dogs live in your household?

Household Members' Information

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.

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.
Coordinated Site Delivery*
Please choose delivery location:
Name of Agency*
Please note: Individual Delivery must be arranged in advance, email pantry@amherstsurvival.org.
Other notes/comments:
Information verification*
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.
- Please check before submitting this form
Name*
First Last

Food Pantry Online Registration

Annual Food Pantry Household Declaration Form

Household Information

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