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  • NEW Client Intake Form

    NEW Client Intake Form

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    haga clic en la bandera en la esquina superior derecha.

    Pou chanje lang fòm nan, klike sou drapo ki nan kwen anwo dwat.

     

    Please complete this application to become a client of Mothers Helping Mothers.

     

     

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  • Please enter your name EXACTLY as it is on your photo ID - Drivers license or Passport.

  • Format: (000) 000-0000.
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  • Format: (000) 000-0000.
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  • Please indicate if any of these situations apply to you so that we can provide you with appropriate resource information.

    • Click here to enter second situation 
    • Click here to enter another situation 
    • Please click the blue NEXT button to continue 
  • Mothers Helping Mothers - CLIENT AGREEMENT CONTRACT 
      
    ELIGIBILITY: I understand that items provided at MHM are for those that cannot afford such items and I will only use the store as needed to supplement by household income based on my current financial circumstances. 
    POLICIES: 
    •         Clients are permitted to shop once every four months 
    •         Client Photo ID (passport or driver license) must be shown at each visit 
    •         Clients are allowed to shop for their immediate family only (spouse and direct  registered dependents only) Spouses will be added to the main client's account and will not have their own  separate accounts. 
    • . Clients may bring only ONE member of the family in the store to help them shop IF and only  IF it is necessary. Otherwise, they will be asked to wait in the car. 
    •        Parent must bring Social Security cards or other legal documentation to register their children or they will not be allowed to shop for them. 
    •         Proof of pregnancy is required to shop for any baby items 
    •        Baby items are not to be taken if pregnant until 30 days before the baby is due and proof of  pregnancy is required. Clients may return again early to collect these items prior to delivery if they still have needs 
    •          Clients may not shop for other family members unless management makes an exception 
    •         Only members registered in the clients file are to receive items taken from Mothers. 
    •         One appointment should be made for EACH household separately and not for multiple  family members. They will need to make a separate appointment for their own family. 
    •          Items taken from MHM should be returned to MHM if they are no longer needed. Selling any item taken from MHM is grounds for removal from our system - NO exception 
    Any violation of these policies may result in termination as a client. 
      
    MERCHANDISE WAIVER: Clients assume all responsibility for the safety inspection, proper installation, and proper use of all donated items. MHM will not be held liable for a client's failure to adhere to all safety guidelines. 
    MEDIA RELEASE: I hereby grant full permission to any and all the foregoing to use my name and/or likeness in any broadcast, telecast, video, or print media reporting and/or publicity without compensation for marketing and donor purposes. 
    LIABILITY WAIVER: I understand and agree that neither Mothers Helping Mothers, Inc., nor its trustees, officers, directors, agents or representatives may be held liable in any way for any injury, harm or damage while on the premises and hereby release MHM, its trustees, officers, directors, agents and representatives from any liability. 
    MEDICAL: I authorize MHM, Inc. through its trustees, officers, directors, agents or representatives to render or obtain such emergency medical care or treatment for me as may be necessary should any injury, harm or accident occur to me while participating in this activity. 


  • I acknowledge that I have read this "waiver and release" and fully understand that it is a release ofliability. By my signature below, I am waiving any right I may have to bring legal action to assert a claim against MHM and its officers.

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