THE PANTRY @ ACC APPLICATION FORM General Information (Please print legibly): Asnuntuck ID Number: _______________________ E-Mail Address: ________________________________ Zip code: State of Residence: CT: _______ MA: ______ Ethnicity (Choose all that apply): Caucasian: ____ African American/Black: ____ Latino: ____ Asian: ____ Middle Eastern: ____ Pacific Islander: ____ Native American/Alaskan: ____ Other: ____ Birthdate: ____ Gender: Male: ___ Female: ___ Transgender: ____ Other: Campus Status (Mark all that apply in each row): Full-Time Status: ____ Part-Time Status: ____ Traditional Student: ____ Non-Traditional Student: ____ Veteran: ____ Employee: ____ Household Information: How many individuals are in your household? ____ How many of those individuals are under the age of 18? ____ Children: Ages: Do you have personal transportation? Yes: ____ No: ____ Are you employed? Yes: ____ No: ____ If ‘Yes,’ Full-Time: ____ Part-Time: ____ How many people in your household are employed? ____ Do you receive any other food assistance? Acceptance of Free Food and Waiver of Liability: By my signature I acknowledge the receipt of free food from the food pantry. I understand this is a gift and not a reoccurring obligation by the college, food pantry, or fiscal sponsor. I further 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 food, college, its officers, agents, employees, students, donors, volunteers, and food suppliers. Signature: ________________________________ Date: _______________________
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