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Community Health Program Donation Form
Continue to schedule donation drop off time.
3
Questions
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1
What type of donation do you have?
*
This field is required.
Though everything is appreciated because of the nature of our clientele not everything can be accepted. Please select the type of donation you have. If your donation isn't listed, please STILL feel free to still fill out the form chose "other", as the needs of our clients can vary, one of our community health workers will reach out within 24 hours.
Please Select
Diapers
NEW/GENTLY used baby items.
Gas cards/gift cards
Furniture
OTHER
Please Select
Please Select
Diapers
NEW/GENTLY used baby items.
Gas cards/gift cards
Furniture
OTHER
Thank you
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2
Name
*
This field is required.
First Name
Last Name
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3
Phone Number
*
This field is required.
Will be used to confirm drop off time.
Please enter a valid phone number.
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