Test page for Food Pantry Registration Annual Food Pantry Household Declaration Form Today's Date: Month Day Year Household InformationHead 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 Pronouns She/Her They/Them He/Him Other Gender Female Male Gender-neutral Prefer not to identify Email Your physical street address (no PO Box):* Town:*AmherstBelchertownDeerfieldGranbyHadleyLeverettPelhamShutesburySouth DeerfieldSouth HadleySunderlandWareWhatelyOtherYour townIf your town is not on the list above, please list it here: Zip Code PhonePlease 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.1234567891011121314Household Income*Please choose the amount which shows your annual income (total income earned by all household members in a year): $0-$20,950 $20,951-$34,900 $34,901-$36,450 $36,451-$55,800 $55,801+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$23,950 $23,951-$39,850 $39,851-$49,300 $49,301-$63,800 $63,801+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$26,950 $26,951-$44,850 $44,851-$62,150 $62,151-$71,750 $71,751+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$29,900 $29,901-$49,800 $49,801-$75,000 $75,001-$79,700 $79,701+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$32,300 $32,301-$53,800 $53,801-$86,100 $86,101-$87,850 $87,851+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$34,700 $34,701-$57,800 $57,801-$92,500 $92,501-$100,700 $100,701+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$37,100 $37,101-$61,800 $61,801-$98,850 $98,851-$113,550 $113,551+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$39,500 $39,501-$65,750 $65,751-$105,250 $105,251-$126,400 $126,401+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$41,850 $41,851-$69,700 $69,701-$111,600 $111,601-$139,250 $139,251+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$44,250 $44,251-$73,700 $73,701-$117,950 $117,951-$152,100 $152,101+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$46,650 $46,651-$77,700 $77,701-$124,350 $124,351-$164,950 $164,951+ Household Income*Please choose the amount which shows the income you earned (including earnings of anyone age 18+ in your household): $0-$49,050 $49,051-$81,650 $81,651-$130,700 $130,701-$177,800 $177,801+ Benefits*Does ANYONE in your household receive any of these benefits? Please check all that apply. Veteran Aid MA Health/Medicaid TANF Fuel Assistance SSI SNAP (Food Stamps) WIC TAFDC Other No Benefits Other benefits*List other benefits: Race* White Black/ African American Black/ African Black/ Cape Verdean Black/ Caribbean Islander East Asian/ Pacific Islander South Asian/ Indian Native Alaskan American Indian Multi/Mixed Race Prefer Not to Specify Other Ethnicity* Latino/a/x or Hispanic Not Latino/a/x or Hispanic Preferred language*EnglishChinesePortugueseSpanishOtherpreferred language*Your preferred language: Gender*Gender: Pronouns*Pronouns: Are you experiencing homelessness?* Yes No Are you a veteran?* Yes No Are you disabled?* Yes No Diet*Do any of the following apply? Vegan Dairy Free Gluten Free Nut Allergy Vegetarian Kosher Halal No Preferences Other dietary/special requestsPlease list:Heard about ASCHow 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 Other ASC referral*Please tell us where you heard about us. 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 authorizationDo you authorize anyone OUTSIDE your household to pick up your groceries?NoYesIndividual/Agency*Please list the individual or agency you would like to pick up your groceries on your behalf. Does your household have transportation to the ASC? Yes No Do you need delivery?*NoYesFrozen ProteinWhat is your household’s protein preference? Chicken Turkey Beef Pork Fish Vegetarian Incontinence productsDo you need incontinence products? Bed pads Adult briefs Diapers Adult briefs genderMaleFemaleAdult briefs sizeWomen's SmallWomen's MediumWomen's LargeWomen's X-LargeMen's SmallMen's MediumMen's LargeMen's X-LargeDiaper sizeSize 1Size 2Size 3Size 4Size 5Size 6Menstrual products?Do you need menstrual products? Tampons Pads How many cats live in your household?01234+How many dogs live in your household?01234+Household Members' InformationPlease 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 Edit Delete There are no Household Members listed. Add Household Member 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. Coordinated Site Delivery*Please choose delivery location:Amherst: Boulders ApartmentsAmherst: Brandywine ApartmentsAmherst: Butternut Farms ApartmentsAmherst: Colonial Village ApartmentsAmherst: Olympia Oaks Apartments Amherst: Presidential ApartmentsAmherst: Rolling Green Apartments Amherst: Senior DeliveryAmherst: Senior Delivery- Chestnut Court Apartments Amherst: Senior Delivery- Clark House Apartments Amherst: Senior Delivery- Ann Whalen ApartmentsAmherst: Village Park ApartmentsAmherst-University VillageBelchertown: Senior CenterBelchertown: Senior Delivery-Everett AcresHadley: Golden Court & Burke Way ApartmentsHadley: Mountain View ApartmentsHadley: Senior CenterPelham: Senior DeliverySunderland: Cliffside ApartmentsUMass Student Dorms–Without KitchensUMass Student Dorms–With Kitchens Ware: Hillside Village ApartmentsWare: Senior DeliveryWare: Senior Delivery-Church Street ApartmentsWare: Senior Delivery-Valley View ApartmentsAgency Supported Delivery (list agency in next field)OtherName 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
