Amazon Gift Card Program
Victims Of A Crime Advocacy Program
The following survey is for potential enrollment in the Amazon Delivery Program .
Application opens January 1st of each year and closes on December 31st. Applicants must apply annually. ____________________________________________________________________________________________________Grant Information: California Office of Emergency Services has funded The Ark of Refuge,Inc for the disbursement of Federal funds from the Victims of a Crime Act. 40 Applicants receive a one-time $450 Amazon gift card . Clients must apply annually for benefit. ____________________________________________________________________________________________________Applicant Requirements: Victim of a Crime, Current or a Former Domestic Violence Victim. Delivery of Funds: Funds are disbursed on the 1st of every month starting April 3rd of each year retroactively paying January 1st to April 1st applicants. Clients can opt to receive a digital gift card or physical. ____________________________________________________________________________________________________Comments and Questions regarding this program shall be directed to : Leslie West, food.arkofrefuge@gmail.com; +1(866)676-0070
STOP! DID YOU FILL OUT THE CLIENT INTAKE FORM ?
Please Select
Yes
No
Before requesting services you must fill out the client intake form or your application WILL NOT be processed. If you have not already done so , please copy and paste this link into your browser and return to this application once complete. Link: https://form.jotform.com/Ark_Refuge/client-evaluation-form
Application Submission Month
Please Select
1. January
2. February
3. March
4. April
5. May
6. June
7. July
8. August
9. September
10. October
11. November
12. December
This application is a ONE-TIME benefit on an ANNUAL basis. Please select from the drop-down list below the month you are submitting this application. Previous recipients must wait 12 months before re-applying.
Referral Source
*
Please Select
1. Friend/Relative
2. Oakland Elizabeth House
3. Report A Victim (Website Form)
4. Heritage Hospital - Sacramento
5. Street Outreach Team ( Foot Canvass)
6. Called Crisis Hotline (+1-866-676-0070)
Please indicate which of the following are true for you (check all that apply) If none, you are not eligible to receive services
Victim of a Crime
Housed DV Victim- Single Adult
Housed DV Victim- Family
DV Victim Homeless with a Family
DV Victim - Homeless withOUT a Family
Elder Abuse ( Over age of 60)
None of the above
Name
First Name
Last Name
My Products
prev
next
( X )
Amazon Gift Card
Permanently Housed Victims of a Crime
$
450.00
Quantity
0
1
Item subtotal:
$
0.00
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
What County do you live in?
*
What is your age?
*
Please Select
Under 12 Years Old
12-17 Years Old
18-24 Years Old
25-34 Years Old
35-44 Years Old
45-54 Years Old
55-64 Years Old
65-74 Years Old
75 Years or Older
Prefer Not to Answer
How do you identify racially?
*
Please Select
African-American/Black
White/Caucasian
Native American
Alaska Native
Native Hawaiian
Asian American and/or Pacific Islander
Two or More Races
Person of Color
Other
Prefer Not to Answer
If you selected other, please specify:
How do you identify ethnically?
*
Please Select
Hispanic and/or Latinx
Non-Hispanic/Non-Latinx
Prefer Not to Answer
What is the primary language spoken in your household?
*
Please Select
English
Spanish
Chinese
Tagalog
Vietnamese
Arabic
French
Korean
Russian
German
American Sign Language
Other
Prefer Not to Answer
If you selected other, please specify:
Do you identify as a member of the LGBTQ+ community?
*
Please Select
Yes
No
Prefer Not to Answer
What is your gender identity?
*
Please Select
Woman
Man
Non-Binary
Gender Fluid
Agender
Unsure
Prefer Not to Answer
Other
If you selected other, please specify:
Do you identify as transgender?
*
Please Select
Yes
No
Prefer Not to Answer
Do you identify as someone with a disability?
*
Please Select
Yes
No
Prefer Not to Answer
Are you currently homeless ?
*
Please Select
Yes
No
Prefer Not to Answer
Are you a current or former foster youth ?
*
Please Select
Current
Former
None
What is your military status?
*
Please Select
Veteran
Child (under 18) of a Veteran
Active Duty
Not a Veteran
Prefer Not to Answer
In the following questions, you will be asked about specific instances in which you may have experienced a criminal and/or violent act.
A brief definition of each will be provided.
Have you ever been the victim of domestic violence? (Physical injury committed by a family or household member against another family or household member)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been the victim of human trafficking? (The use of force, fraud, or coercion to obtain some type of labor or commercial sex act from another person)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been the victim of kidnapping? (Forcibly, secretly, or by threat confining, abducting, or imprisoning another person against their will)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been the victim of elder abuse? (Intentional acts by a caregiver that cause significant impairment to an elderly adult's physical, mental, or emotional health)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been the victim of a robbery? (Taking money or property from another person through the use of force, violence, assault, or threat)
*
Yes
No
Unsure
Prefer Not to Answer
Have you or a family member ever been a victim of or witnessed a homicide? (When one human being causes the death of another, which includes accidents/manslaughter, self-defense, or premeditated murder)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been a victim of a hate crime related to your sexual orientation and/or gender identity or expression? (A crime motivated by bias against or hatred towards someone due to their sexual orientation and/or gender identity)
*
Yes
No
Unsure
Prefer Not to Answer
Have you ever been a victim of a hate crime targeting any other identity (such as racial, ethnic, or religious identity)?
*
Yes
No
Unsure
Prefer Not to Answer
If you were the victim of one or multiple crimes, did you seek out support from any of the following resources? (can select multiple)
*
Medical professionals
Domestic violence and/or sexual violence survivors shelters
VA services
Military family and social services
Hotline
Law enforcement
Family
Significant other
Friend
Mental health provider
Other victim service providers
Did not use any resources
Have not been a victim of a crime
Prefer not to answer
If you selected yes to any of the resources above, do you feel that you received adequate support?
*
Yes, very positive experience
Mixed, overall positive experience
Mixed, overall negative experience
No, very negative experience
Have not been a victim of a crime
Prefer not to answer
Have you ever been denied services due to your race/ gender and/or sexual identity?
*
Yes
No
Unsure
Prefer not to answer
Name
*
First Name
Last Name
Method of Amazon Gift Card Delivery?
*
Please Select
Digital Gift Card (Email)
Physical Gift Card (USPS Mail)
Signature
*
Thank you for participating! We greatly appreciate your time and effort.
These funds are being distributed with no barrier in accordance with the VOCA ACT and CALOES SRH. A representative will be in contact within 48 hours. Feel free to visit our website at www.TheArkofRefuge.com for additional programmatic information.
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