Assistance Request Form
Date of Weather Event
*
-
Month
-
Day
Year
Date
Applicant Information
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Address of Primary Residence Affected
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Damage Type
*
Wind
Water
Flood
Other
Please describe the extent of the damage.
*
Please upload a picture of your driver's license to verify the location of affected primary residence.
*
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Alternate address if needed to receive approved donation.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Members of Kappa Alpha Phi Fraternity, Inc., please provide your Province
Province
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