Ruth's Portion Food Service Request Form
Please complete all required fields.
Email address *
Last Name *
First Name or Initial *
Telephone Number *
Gender *
Marital Status *
Parent Household *
Hampton Roads City *
Zip Code *
Race *
# of people in the household *
# of children in High School *
# of children in Middle School *
# of children in Elementary School *
# of toddlers (2-4 years old) *
# of infants *
Anyone in the household receiving prenatal care? *
Would you like other services *
If yes, please check all that apply
Are you a member of of a church *
Church name, city, state
How did you hear about KĀMO/Ruth's Portion Food Outreach? *
Today's Date *
MM
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DD
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YYYY
eSignature *
Type your name as a signature acknowledging request for food from the KĀMO: Ruth's Portion Food Outreach.
Waiver and Release of Liability *
KĀMO is a 501(c)3 Nonprofit organization, public charity. By the acknowledgment of this agreement, I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me, and I hereby fully and forever release and discharge the Kingdom Authority Ministries Outreach dba KĀMO (The NPO), Ruth's Portion Food Outreach, its Officers, Directors, Volunteers, Associates, or Affiliates from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising from information, materials, or food items received. I expressly agree to indemnify and hold harmless Kingdom Authority Ministries Outreach dba KĀMO, Ruth's Portion Food Outreach against any and all claims, demands, damages, rights of action, or causes of action, of any person or entity, that may arise from injuries or damages sustained by me or my guest. I HAVE READ THE FOREGOING WAIVER AND RELEASE OF LIABILITY AND VOLUNTARILY EXECUTED THIS DOCUMENT WITH MY eSIGNATURE KNOWLEDGE OF ITS CONTENT. (type your name followed by your zip code as an eSignature)
Please allow 24 - 48 hours for our Care Team to coordinate the delivery of the Ruth's Portion Food Service request. Thank you!
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