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 : ___ F emale : ___ Transgender: _ ___ Other : Campus Status (Mark all that apply in each row): Full - Time Status: _ __ _ Part - Time Status: _ __ _ T raditional 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: _______________________