Community Wash Day Registration

Peace and blessings to all of the phenomenal mothers and caretakers that are doing it on their own. This Thursday you are invited to join us at Revolution Laundry located on 252 S 60th St, Philadelphia, PA 19139. This event is from 1 pm to 5pm and in order to participate you must complete this form.

As you fill out this registration form we will be asking some personal questions because we would like to get to know you and we would like to know what services will best suit your needs. We all know that being a mother can be overwhelming yet and still a mother will find a way through any situation if it is to provide for their children. If you are filling out this registration you have met the requirements of those we are seeking to help. As for the personal questions you are always at liberty to not answer And we have giving you that option to do so. We just want the women to know that we are a support system that will cater to each and every need that we come across.

Name*

First NameMiddle initial Last Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

E-mail*

Contact Number:*

Area CodePhone Number

Faatumily sts *

Have you been in your home for less than a year.*

Are you in need of household products*

Are you currently working *

Please be honest. You’re answer does no effect you participation.

HOW MANY CHILDREN DO YOU HAVE UNDER THE AGE OF 18?*

Infant to 66 to 1213 to 18No girls

Number of girls*

Infant to 66 to 1213 to 18No boys

Number of boys*

Are you open to talking about and receiving information on mental health. *

We will have license African-American female therapists and life coach is available for those who would like assistance.

Are you currently on public assistance? *

Please be able to provide your unemployment or Snap benefits

Do you have life insurance?*

We will connect you with a licensed agent to answer all your questions.

Have you ever been a victim of domestic violence?*

We operate in complete discretion and we understand that domestic violence is very real as well as taboo topic. However, if you Or somebody you know needs assistance please feel free to reach out.

Does anyone in the household have record? And are you interested in expungement services?*

You may only sign up for one community wash day per month. Do you agree to only sign up for 1*

Revolution Laundry 252 S 60th St, Philadelphia, PA 19139 ·

Do you have a savings account for your children?*

Do you currently have a family member that is incarcerated?*

Do you have a bank account?*

No personal information is neededNo personal information is needed

Do you have a washer dryer hook up in your home or apartment?

ARE YOU IN NEED OF A NEW REFRIGERATOR?

Refrigerator must be broken and or show dire need for refrigerator

How many children will you be bringing to the event between newborn and age 18.*

Kids of the participating families will be allowed at the event. Please keep in mind that if you are bringing your children that you should let us know so that way we can have a proper headcount to provide masks to those who do not have them. We do encourage families to bring their children for we will be giving away food and snacks and will also have services for them.

You are only allowed to bring clothes and sheets, No big blankets, no comforters and no sneakers. Unfortunately if these items are brought we will not be able to wash them.

Do you agree to the above terms.*

Have you ever participated in a community wash day so far or have received any services from SistaTALKPHL.*