Intake Form

Temporary Assistance

Intake Form
Date

MonthDayYear
Date
Name

First NameLast Name
Email
example@example.com
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How many people in your Household?
Please describe your current situation:
Select the type of assistance requested:
Amount requested or estimated need:
Have you received support from BeautiLuxCAKC Cares before?
Additional information you would like us to know:
Please submit any supporting documentation to support need.

Cancelof
You may be asked to provide additional documentation depending on the type of support requested.

Submission of this form does not guarantee assistance.
Signature
Should be Empty:

Temporary Assistance