Culture Bearer Emergency Intake Form
All information submitted through this form will remain confidential and will only be used for internal review, verification, programmatic, reporting, and support purposes by Feed the Second Line. Please allow approximately 24–72 hours for review and follow-up communication regarding your request. Submission of this form does not guarantee assistance, funding, services, or support, as all assistance is based on eligibility, organizational capacity, and available funding.
Jotform Type
Name
*
First Name
Last Name
Email
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: 0000000000.
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What Entity Of The Culture Are You Affiliated With
*
What Entity Of The Culture Are You Affiliated With
*
Mardi Gras
Masking Indian
Baby Doll
Second Line / Social Aid & Pleasure Club
Brass Band Musician
Other
Are you requesting utility or rent assistance?
*
Yes
No
If you selected yes, please upload your current utility bill, disconnect notice, or lease. Other documents may be required
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Details About Emergency
*
Required Acknowlegements
*
I understand that Feed the Second Line may request additional information, documentation, or verification related to cultural participation, programming, support, opportunities, or cultural affiliations.
*
I understand that submitting this intake form does not guarantee assistance, participation, funding, sponsorship, services, or support from Feed the Second Line, as all opportunities and assistance are based on program eligibility, organizational capacity, and available funding.
*
I understand that providing false, misleading, or inaccurate information may result in denial of assistance, removal from programs, suspension of participation, or ineligibility for future support and opportunities from Feed the Second Line.
Name
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: