First Name *

Last Name *

GVSU G-number *

GVSU Student E-mail Address *

Do you live on-campus? *
- Select Option Yes No

Gender: *
- Select Option Woman Man Transgender Not listed Please specify a value for Gender:

Race/Ethnicity: *
- Select Option White Hispanic/Latino Middle Eastern Asian Black or African American Multiethnic Native Hawaiian/Pacific Islander American Indian or Alaskan Native Not listed Please specify a value for Race/Ethnicity:

What is your current student status? (Check all that apply) *
Undergraduate student
Graduate student
International student

Do you identify as any of the following? (Check all that apply) *
Vetran
Student parent
Student Athlete
Non-traditional Student
A member of the LGBTQIA+ Community
N/A

Do you have any dependents? *
- Select Option Yes No

How many dependents do you have? *

Are you or anyone else in your household pregnant? *
- Select Option Yes No Prefer not to answer

Were you ever in foster care? *
- Select Option Yes No Prefer not to answer

Do you have a documented disability? *
- Select Option Yes No Prefer not to answer

Have you heard about Replenish? *
- Select Option Yes No

Have you used Replenish in the past month? *
- Select Option Yes No

Have you ever skipped a meal or gone without eating in the past month? *
- Select Option Yes No

Do you have an active meal plan? *
- Select Option Yes No

Have you been in contact with Financial Aid regarding your food concerns? *
- Select Option Yes No

Would you like someone to contact Financial Aid regarding your food concerns? *
- Select Option Yes No

Do you have other concerns that we can assist with or that you would like us to follow up about? *

How did you hear about the Replenish Emergency Dining Cards? *