RESTkc Business Intake Form

RESTkc Business Intake Form
Thank You for Your Interest in RESTkc !

This form helps us learn more about your business and determine if RESTkc would benefit from a relationship.

RESTkc serves families of children with significant ongoing medical complexity. Eligibility is based on the level of medical caregiving and support the child needs over time, not diagnosis alone.

Please complete this form as fully as you can. If you are unsure about an answer, your best estimate is okay. You may also use your own words anywhere additional context would be helpful.

At this time, RESTkc provides in-home services for families living in Johnson County and Wyandotte County, Kansas, and inpatient services for families receiving acute hospital-based care in the KC metropolitan area.

All fields are optional unless marked required (*).

Section 1 - Basic Information
Name

First NameLast Name
Business/Organization Name
Title/Role
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Preferred Method of Contact

Section 2 - Organization Overview
How are you interested in supporting RESTkc?
e.g.: providing services, financial support/donations, item donations, etc.
Brief description of services, products, or support

Section 3 - Additional Information
Anything else you would like us to know?
Interest in being featured as a community partner
Website and/or Social Media

Should be Empty: