Food Assistance Student Questionnaire
Thank you for reaching out to find out more about Food Insecurity solutions at Bucks. We would like to assist students who are facing food insecurity. In order to assist you as quickly as possible, p
lease complete the following fields.
You will receive a response within two business days.
*
Required Fields
Contact Information
First Name
*Required
Last Name
*Required
Student ID
*Required
Please enter your current mailing address:
Address
*Required
Address 2
City
*Required
State/Province
*Required
Alabama
Alaska
Alberta
Arizona
Arkansas
Armed Forces Americas
Armed Forces Other
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland & Labrador
North Carolina
North Dakota
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
Washington DC
West Virginia
Wisconsin
Wyoming
Yukon
Zip/Postal Code
*Required
Age
*Required
Phone
*Required
Please check if it is okay to leave you a detailed message at the phone number provided.
Bucks Email Address
(Must use a Bucks email address)
*Required
Your entry is not a valid email address!
How did you learn about this program?
*Required
Enrollment Status
*Required
Part time
Full time
Other (Please specify below)
If applicable, please specify:
Gender
*Required
Female
Male
Other
Employment?
*Required
Part time
Full time
N/A
How many people in your household are under the age of 18?
*Required
How many people in your household are employed?
*Required
Do you or anyone in your household receive any of the following benefits. Please select all that apply.
SNAP
TANF
WIC
KEYS
Are you a veteran?
*Required
Yes
No
What campus do you attend most?
*Required
Newtown Campus
Upper Bucks Campus
Epstein Campus at Lower Bucks
Other (please specify below)
If you selected other, please specify:
Additional Comments:
By typing your name in the box below, you understand that the information/answers provided are complete and true and you further agree to the following: You understand that this is to be used as an emergency resource only and is meant to supplement additional assistance or resources you may receive, you will not sell, exchange or barter any products received, and you understand that the demographic information provided is to assist with future funding. (Private information is not shared externally).
I agree to the above statement. Please type your first and last name:
*Required
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