Kyra's Child LLC Intake Application
Name:
Your answer
Address:
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Phone:
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Email
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What kind of equipment are you needing assistance with? ( Please be as detailed as possible)
Your answer
Describe the issue/issues you are having with your current DME, mobility challenges and other issues.
Your answer
Income (monthly or yearly):
Your answer
Income verification:
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Type of service requested:
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Troubleshooting (please describe your problem to the best of your ability):
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Service ( Describe what kind of in home or hands on service your equipment or you need to the best of your current knowledge):
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Basic Demographic Information
Note: The following is completely voluntary and will only be used for nonprofit status and grant purposes.
Age:
Your answer
Sex:
Race:
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