ASMC Food Pantry Application
Spring 2020
To access the ASMC Food Pantry all students will be required to complete an application prior to coming to the
food pantry. This form will allow us to track and report necessary information to the California Community
Colleges Chancellor’s Office and the Merced County Food Bank.
Students will be required to complete an application every semester. Once your application has been received
and reviewed you will be notified and given an ASMC Sticker for you ID card. This will allow you access to the
food pantry.
Date:
First Name: Last Name:
Student ID #: First Time Using Pantry: Yes No
Email:
Gender: Age: How many in the household are: (including yourself)
Male Ethnic Background: Disabled
Female Hispanic Female Head of Household
Other American Indian/Alaskan Indian Homeless
Decline American Indian/Alaskan Native & Black Veterans
Indian/Alaskan Native & White Over 62+
Asian Foster Youth or Former Foster Youth
Asian & White
Black/African American
Black/African American & White American
Native Hawaiian/Pacific Islander
White
Other Multiracial
Income Categories: City:
Extremely Low Income Cathey’s Valley Hilmar Planada
Very Low Income Coulterville Le Grand Santa Nella
Low Income Delhi Livingston Snelling
Medium Dos Palos Los Banos Winton
El Nido Mariposa Other
Gustine Merced
Do you receive CalFresh Benefits? Yes No
If No, have you applied for CalFresh Benefits? Yes No
How did you hear about the Food Pantry?
Class Announcement
ASMC Website
Flyer
Counselor
Professor
Staff Member, Administrator or Manager
Submit
SUBMIT
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