First Name *

Last Name *

GVSU G-number *

GVSU Student E-mail Address *

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

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

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

Have you already used your two Replenish visits for this 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

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? *

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:

Do you identify as any of the following? (Check all that apply)
A member of the LGBTQ+ Community
Disabled
Formerly in foster Care
International Student
Non-Traditional Student
Student Athlete
Student Parent
Veteran