Kamu Kind Heart: Application for Hamper
Kamu Kind Heart intends to bring social relief to single parents and persons who require support with their basic needs for themselves and immediate family members. This form would aid in us tailoring a care package that fits your family needs. We shall only obtain and use personal information for those purposes which are known to individuals or which are within their expectations and are relevant to us.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How much persons are in the household, including children? Kindly provide age group of the children under 16.
How do you support yourself? (Select all that applies)
Employed
Family
Government
Other
Do you or anyone in the household receive, Pension, Public or Disability assistance?
Yes
No
If yes to the above question, please indicate which applies. If not, please select N/A
Pension
Disability Grant
Food Card
N/A
Household expenses. (Please select all that applies)
Rent
Cable
Internet
Utilities
Higher Purchase
Other
Briefly describe why you require support from Kamu Kind Heart.
Please provide a valid ID/DP number that would be presented when collecting.
I hereby affirm the veracity and accuracy of the information submitted on this application form. I am cognizant that any inaccurate or misleading information provided on this form may result in the revocation of my application..
Yes
Submit
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