Boots on the Ground by Project G.A.P. Pantry Assistance Application

Boots on the Ground by Project G.A.P. Pantry

(God Answering Prayers)
Diamond Excursions Ladies' Edition is a 501(c)3 nonprofit organization that offer programs, and services, and fill gaps on insecurities.

Our programs includes:

• Boots on the Ground by Project GAP, an outreach program that mobilize resources, and host Resource Pop-Ups in underserved communities. Through our partnerships, we deliver donations, bring awarness to resources, and promote businesses.
Contact:bog.projectgap@gmail.com

• MS HUB Complex, Community Resource Center, is being renovated at 6563 Hwy. 49 South Hattiesburg, MS 39401. The facility will offer showers, laundry service, a pantry, hot meals, case workers, licensed therapist, access to mailbox, a mailing address, lockers, a salon, computer room, training, workshops, and job development.
Contact: mshubcom@gmail.com

• Safe Haven Coalition a network of nonprofits, churches, agencies, businesses, organizations, and individuals that come together to help end or prevent homelessness.
Contact: safehavencoalition1@gmail.com

Through these programs we we serve communities, create sustainable change, immediate relief, and long-term solutions. We assist individuals on a case-by-case basis. Our organizations doesn't directly provide services, with your permission, we advocate on your behalf.

Be sure to stay connected to us:

• FB: "Boots on the Ground by Project GAP,*Safe Haven Coalition, or *MS HUB Complex.

IG/Snapchat: bog_projectgap

YouTube: Boots on the Ground by Project GAP (bog_projectgap

Tiktok: Boots on the Ground_PG (bog_projectgap)

"Bridging the GAP Resource Pop-Up Tour travels over Mississippi. Connect to our social media platform for the dates, times, and locations.

Contact Information:

769-207-2711

Diamondexcursionsladiesedition@gmail.com

www.diamondexcursionsladiesedition.com

Someone will contact you upon review of your application, and the availability of services.
Diamond Excursions Ladies' Edition is a 501(c)3 nonprofit organization that offer programs, and services, and fill gaps on insecurities.

Our programs includes:

• Boots on the Ground by Project GAP, an outreach program that mobilize resources, and host Resource Pop-Ups in underserved communities. Through our partnerships, we deliver donations, bring awarness to resources, and promote businesses.
Contact:bog.projectgap@gmail.com

• MS HUB Complex, Community Resource Center, is being renovated at 6563 Hwy. 49 South Hattiesburg, MS 39401. The facility will offer showers, laundry service, a pantry, hot meals, case workers, licensed therapist, access to mailbox, a mailing address, lockers, a salon, computer room, training, workshops, and job development.
Contact: mshubcom@gmail.com

• Safe Haven Coalition a network of nonprofits, churches, agencies, businesses, organizations, and individuals that come together to help end or prevent homelessness.
Contact: safehavencoalition1@gmail.com

Through these programs we we serve communities, create sustainable change, immediate relief, and long-term solutions. We assist individuals on a case-by-case basis. Our organizations doesn't directly provide services, with your permission, we advocate on your behalf.

Be sure to stay connected to us:

• FB: "Boots on the Ground by Project GAP,*Safe Haven Coalition, or *MS HUB Complex.

IG/Snapchat: bog_projectgap

YouTube: Boots on the Ground by Project GAP (bog_projectgap

Tiktok: Boots on the Ground_PG (bog_projectgap)

"Bridging the GAP Resource Pop-Up Tour travels over Mississippi. Connect to our social media platform for the dates, times, and locations.

Contact Information:

769-207-2711

Diamondexcursionsladiesedition@gmail.com

www.diamondexcursionsladiesedition.com

Someone will contact you upon review of your application, and the availability of services.
Head of Household Name (as listed on Valid ID). Photo ID must be presented at your appointment.

First NameLast Name
Nickname
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please include all household members (including the head of household).

Rows	Name of Household Members (including Head of Household)	Date of Birth	Relationship to HOH	Income Yes or No
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What is the head of household martial status?
Spouse/Partner (Only is he/she lives with you:

First NameLast Name
Spouse/Partner Contact Number
Are there any individuals, in the household, over 65 years of age?

Other
Are there any veterans in the household?
Are there anyone in the household disable, as defined by American with Disabilities Act, Section 503 of the Rehabilitation Act of 1973, and/or Section 188 of the Workforce Investment Act?
Are you homeless (HUD definition of homeless is an individual or family that lacks a fix, adequate, regular nighttime residence; who’s nighttime resident is a public or private place not meant for human habitation (car, encampment, woods); or living in a public or private shelter.
For the Unhoused ONLY: Please give the specific location, where you spend most of your time, or sleep at night.
If you and your family are living in a hotel, who is responsible for payment?
What is the name of the organization, church, or nonprofit?
Are you in the Foster Care System?
Have you aged out of the Foster Care System?
Do you have an open case with CPS?
Are you scheduled for an in-home visit, by CPS?
Emergency Contact Name and Number
Emergency Contact Name and Number
Do you have any form or income?
What are your forms of income? Check all that apply.
Do you, your child or children receive Medicaid?
How may we help you? We don’t assist with gas, rent, utilities, car repairs, hotel expenses, stoves, refrigerators, microwave, bath tubs, or recreational habits.
Are there any allergies or dietary restrictions with anyone in the household?
What are the allergies and dietary restrictions?
Have you applied for assistance with another agency, church, nonprofit, or organization?
What is the name of the church, organization, nonprofit, or agency?
Have you ever been denied, sanctioned or kicked off any other programs?
When, what county, and why?
Are you pregnant?
Are or will you be a teen mom?
How far along are you?
Do you need assistance obtaining a photo ID?
Do you need assistance obtaining a social security card?
Do you need assistance obtaining a birth certificate?
Are you registered to vote?
Would you like to register to vote?
Liability Waiver: I, the undersigned participant, acknowledge that I am voluntarily participating in and/or receiving services through programs, activities, events, community initiatives, volunteer opportunities, educational activities, recreational activities, service projects, resource events, workshops, transportation, training, meetings, outings, camps, fundraisers, community clean-up activities, or other activities offered, sponsored, coordinated, hosted, or supported by the Organization and/or its programs, partners, affiliates, sponsors, volunteers, employees, officers, directors, agents, contractors, and representatives.I understand that participation is voluntary and that activities may occur at facilities, properties, vehicles, public spaces, partner locations, or other locations that are owned, leased, operated, or provided by the Organization, its partners, or third parties.
ASSUMPTION OF RISKI understand that no organization can guarantee that an activity, facility, program, event, transportation arrangement, or service will be completely free from hazards.I knowingly and voluntarily assume the risks associated with my participation, including risks that may result from ordinary negligence, conditions of the premises, equipment, activities, transportation, or actions of other participants or third parties, to the fullest extent permitted by applicable law.I agree to follow all reasonable safety instructions, policies, procedures, posted warnings, and directions provided by staff, volunteers, instructors, activity leaders, or authorized representatives.
RELEASE AND WAIVER OF LIABILITY: To the fullest extent permitted by applicable law, I hereby release, waive, discharge, and covenant not to sue the Released Parties from claims, demands, causes of action, damages, losses, liabilities, costs, and expenses arising out of or relating to my participation in the program or activity.This release includes claims involving personal injury, illness, death, property damage, property loss, or other loss arising from risks associated with participation.Nothing in this Agreement is intended to release liability that cannot legally be waived under applicable law, including liability arising from conduct for which a waiver is prohibited by law.
MEDICAL TREATMENT AUTHORIZATIONIf I become ill or injured while participating in an activity, I authorize the Organization and/or its authorized representatives to obtain reasonable emergency medical assistance for me when, in their reasonable judgment, medical attention is necessary.I understand that the Organization is not responsible for the cost of medical treatment, transportation, emergency services, hospital services, medications, or other medical expenses incurred on my behalf.I understand that the Organization is not providing medical care and that volunteers and staff are not necessarily trained medical professionals.I authorize emergency personnel to provide appropriate emergency treatment when necessary.
PERSONAL PROPERTYI understand that I am responsible for my personal belongings.The Released Parties are not responsible for lost, stolen, damaged, or misplaced personal property, except where responsibility cannot legally be waived.I agree not to bring valuables or unnecessary personal property to appointments or activities.
TRANSPORTATIONWhen transportation is offered, coordinated, or facilitated as part of a program or activity, I understand that transportation involves inherent risks, including traffic accidents, delays, weather conditions, mechanical problems, and actions of other motorists.I agree to follow all transportation rules and instructions, including the use of seat belts and other legally required safety equipment.I understand that the Organization may utilize employees, volunteers, contractors, partner organizations, or other authorized transportation providers.This Agreement does not waive any liability that cannot legally be waived.
PHOTO, VIDEO & MEDIA RELEASEI understand that photographs, video recordings, audio recordings, testimonials, or other media may be captured during Organization-sponsored activities.Unless I decline below, I authorize the Organization and its authorized partners and affiliates to use my image, likeness, voice, name, testimonial, or participation in photographs, videos, social media, websites, newsletters, promotional materials, presentations, fundraising materials, and other legitimate organizational communications.
CONFIDENTIALITY & RESPECT FOR OTHERSI agree to respect the privacy and dignity of other participants, clients, families, volunteers, and community members.I will not photograph, record, publish, or share another participant’s private information, personal circumstances, medical information, or other confidential information without appropriate permission.I understand that certain individuals receiving services may be vulnerable or experiencing difficult circumstances and that their dignity and privacy must be protected.
INDEMNIFICATIONTo the fullest extent permitted by applicable law, I agree to indemnify and hold harmless the Released Parties from claims, damages, losses, liabilities, costs, or expenses arising from my own negligent, reckless, intentional, or unlawful acts or omissions, including damage caused by my conduct to persons or property.This provision does not require me to indemnify any Released Party for liability that cannot legally be transferred or waived.
GOVERNING LAWThis Agreement shall be governed by and interpreted under the laws of the State of Mississippi, unless applicable law requires otherwise.If any provision of this Agreement is determined to be invalid or unenforceable, the remaining provisions shall remain in effect to the fullest extent permitted by law.
CLIENT AUTHORIZATION FOR ADVOCACY & INFORMATION SHARINGI, the undersigned client, hereby give my full and voluntary permission for ________________________________ (Organization/Advocate Name) and its authorized representatives to act on my behalf for the purpose of advocacy, case coordination, and connecting me with appropriate community resources and services.I understand that this authorization allows the Organization and its representatives to communicate, advocate, and share relevant information about my situation with third parties, including but not limited to service providers, agencies, nonprofits, government offices, housing providers, healthcare providers, and other resource partners.This authorization includes permission to disclose and discuss the following information as necessary to assist in securing support and services on my behalf: ● My full name● My address● My phone number and/or contact information● My current situation, needs, and barriers● Relevant background information related to my request for assistance. Any other information reasonably necessary to advocate for and connect me with services and resourcesI understand that the purpose of this authorization is to bridge the gap between available resources and my needs, and to allow the Organization to effectively advocate on my behalf to improve access to services, support, and assistance.I understand that I may revoke this authorization at any time by providing written notice to the Organization, except to the extent that action has already been taken based on this authorization.I understand that this authorization is voluntary and is not a condition of receiving general information or non-advocacy services, unless otherwise required for specific programs.
I have read the mission of D.E.L.E. and Project G.A.P. I understand that by completing this application, no promises or guarantees have been made. I will be contacted when service are available for my household. I agree to be patient until I am contacted for service.
Would you like to stay connected with us?
Would you like to volunteer?
Signature
Date

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2 digit month, 2 digit day, 4 digit yearDate
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