Peace and Comfort Kits (P.A.C.K.S.) Program Request Form
This program is for Seniors 60 years old and above. Please complete this form to receive a FREE Peace and Comfort Kit. (Supplies are limited)
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
Phone Number
*
Please enter a valid phone number.
Participation
*
I am a senior 60 years or older
Yes, I would like to receive a Peace and Comfort Kit, (P.A.C.K.S.)
I can pick up Peace and Comfort Kit
I need delivery of the Peace and Comfort Kit
Register
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