Project G.A.P. Pantry Assistance Application

Project G.A.P. Pantry

(God Answering Prayers)
Diamond Excursions Ladies' Edition is a 501(c)3 nonprofit organization that provides service to those in need, affected by a disaster or teen pregnancy. Our programs include a women organization, youth mentorship program, business networking, a mobile pantry and shower trailer. We offer water, food, shoes, clothes, showers, hot meals, care packages, blessing bags, and more. We don't assist with utilities, rent, shelter, gas money, or hotel expenses. We're mobile, and serve the State of MS.

Once per month, we host Boots on the Ground Resource Pop-Up & Shop events. Our goal is to bring awareness to resources, connect, promote, network, advocate, "build bridges and fill gaps." We welcome other entities to join us, as we take it to the streets.

Be sure to stay connected to Boots on the Ground by Project GAP. It's a movement and we're rolling to communities to serve.

Dates, time, and location of setup will be available on our webpage and social media pages.

769-207-2711

Diamondexcursionsladiesedition@gmail.com

www.diamondexcursionsladiesedition.com

FB: Boots on the Ground by Project GAP

IG/Snapchat: BOG_ProjectGAP

YouTube: Boots on the Ground by Project GAP @BOG_ProjectGAP

TikTok: Boots on the Ground_Pg
How can you help us provide the best service and experience?

Complete this form in it's entirety. Be sure to provide us with up-to-date, honest and accurate information. The only way we can assist is if we're fully knowledgeable. We're big on effective, pleasant communication, interactions, and experiences. We meet individuals where they are, no drama, no judgment. None of us are better than the other. We all have fell short. This is only a season, and this season will pass! We ask questions to better serve you and your family. Answers help us find and bring awareness, to you, about other resources. While you go through this season, we want to partner with you and let you know that "God Answers Prayers." Stay the course and keep your head up! If our organization doesn't provide a service you need, we do our best to connect individual to other resources; no guarantees! Our desire is to help!

We can't help everybody but, we can help somebody. Clients that use profane language, are disrespectful, violent, abstructive, malicious, or attempt to harm other guests, staff members, vendors, or volunteer; will be denied service! NO EXCEPTIONS! If you have a bad experience with staff members, vendors, guests, volunteers; we want to hear from you! Don't ever hesitate to contact us.

Sincerely,

Reona Burnett

Founder & Executive Director
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.
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

Household Information

Please include all household members (including the head of household). Please include the correct information on the household members name that it applies to (this is how we package orders).

	Name of others in Household	Date of Birth	Relationship to HOH	Income Yes or No	Male or Female	Shirt Size	Pant Size	Underwear Size	Shoe Size
1
2
3
4
5
6
7
8

What is your martial status?

SingleDivorceSeparatedRather not say
Spouse/Partner Living with you:

First NameLast Name
Spouse/Partner Contact Number
Are there any children living in the household?

YesNoRather not say
How many children in the household? Please be sure to list all household members information on the table.
Are there any individuals, in the household, over 65 years of age?

YesNoOther
Are there any veterans in the household?

YesNoRather not say
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?

YesNoRather not say
Are you homeless (Defined as 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; or living in a public or private shelter)?

YesNoRather not say
If you are homeless, what location are you in? This information is keep confidential, with our organization and staff. It will not be shared! Our organization ask for location to stay connected with you and to provide service.

CampHighway 49 areaHighway 98 areaChanges Resource CenterAbandon HouseField House for the HomelessLoftin HouseLongleaf TrailsHotelFamily YMCASalvation ArmyHighway 11Live in CarLive with RelativeIn between situationsOtherHotel
If you and your family are living in a hotel, who is responsible for payment of the room?

self payFamily and FriendsChurchNonprofit
If a church or nonprofit is assisting with hotel expenses, what is the name of the organization?
Emergency Contact Name and Number
Emergency Contact Name and Number
Do you have any form or income?

YesNoRather not say
What are your forms of income? Check all that apply.

EmploymentSelf-employedChild supportAlimonyRetirementSSI/DisabilityTANFUnemployment
What are your “Primary Concerns?” We don’t assist with rent, shelter, car payment, utilities, gas, or hotels.
What are your “Primary Needs?” Choose one ONLY! We recommend you choose an immediate need. Furniture and household items are reserved for families with open CPS cases, elderly, veterans, homeless, grandparents with grandchildren, foster children, and those transitioning from homeless to housed. Proof is required.

Clothes & ShoesFurnitureFood BoxHygieneHousehold itemsReferralsPampers and WipesHousing SearchEmployment SearchMental Health CounselingWaterCleaning SuppliesTransportationBus PassesOther
If other, what are your needs?
Are there any allergies (food, brands, or color foods you avoid, in the household?

YesNoRather not say
What are they? Which household member does the allergy apply to?
Have you applied for assistance with another agency or organization? If you have applied or received service from another organization, it doesn’t stop you from receiving service.

YesNoN/A
If so, where?
Have you ever been denied, sanctioned or kicked off any other programs?

YesNoN/A
If so, when and from where?
Assistance Presently Receiving:

SNAPTANFMedicaidWICVeteran’s AssistanceFoodShelterAFDCAssistance from another agencyHeadstart Program
Are you pregnant?

YesNoUnknown
Are/will you be a teen mom?

YesNoOther
How far along are you?

First Trimester (1-3)Second Trimester (4-6)Third Trinester (7-9)
How can we help? We have a program for teen moms however, we can assist others.

ShelterClothes, T-shirts, Socks, Hats, MittensFormulaDiapers/PampersBottles & PaciferBlanketsCar SeatBeddingBaby BagCounselingMentorAdvisor/AdvocateParent PlannedhoodAdoptionEducationLife skillsJob SearchCreating a ResumeInterview SkillsTransportation (to and from appts, school, or work).HealthcareOther
If other, how can we help?
Do you have a current Photo ID? All clients must bring his/her ID to the appointment or to shop on the Panty Trailer.

YesNo
If you don’t have a current ID, are you interested in obtaining one?

YesNoRather not say
Are you a registered voter?

YesNoRather not say
If not, would you be interested in registering?

YesNoRather not say
Clients are required to sign a Liability Waiver before service is rendered. Are you willing to sign a waiver? No service will be rendered without a waiver!

YesNo
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.

I agreeI disagree
Would you like to stay connected with us?

YesNo
Would you like to volunteer?

YesNo
I acknowledge that all the above information is true to the best of my knowledgeI agree to keep all my information current so that I maybe contacted
Signature

Clear
Date

MonthDayYear
Date
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