Keeping Families Covered
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Email *
DIRECT-TO-CLIENT INTAKE FORM
Contact Information
Referred by: *
Full Name: *
Address: *
City: *
State: *
ZIP Code: *
Email: *
Cell Phone: *
Required Information
Please note that your request will be denied if you fail to provide the required information.
Date of birth: *
MM
/
DD
/
YYYY
Are you receiving help from other agencies? *
If yes, which agencies? *
Driver's license number: *
State: *
Marital status: *
Race: *
Required
How did you hear about Keeping Families Covered? *
How many children (under the age of 18) are in your household ? *
How many adults are in your household? *
How many adults in your household work outside of the home? *
What is the total annual income for your household? *
How many adults in your household are parenting at home (stay at home parents who are not working outside the home or looking for other work)? *
How many adults in your household are currently looking for work? *
How many adults in your household are students? *
Are you a military family? *
Is anyone in your household eligible for WIC/SNAP/Food Stamps? *
Would you like information about additional community resources that might be available to you? *
The following forms of identification are required to receive assistance:
      Government Issued Photo ID (Driver’s License, State ID, Military ID, VISA, passport) for parent
      Birth Certificate (for every child in need of assistance)
Family Information & Items Needed
Per our policy, we do not provide any items for unborn children. If you are currently pregnant, we can help you with maternity wear until your delivery. Once your child is born and you have their birth certificate, you are welcome to apply for assistance for them.
If you are pregnant and need maternity wear, please select your size:
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Please list the first names of the children and what each needs. Sizes must be provided for clothing and shoe requests.
Child 1 Name: *
Child 1 Age: *
Child 1 Gender *
Child 1 Clothing Size *
Please list desired items for Child 1 : *
Child 2 Name:
Child 2 Age:
Child 2 Gender
Clear selection
Child 2 Clothing Size
Please list desired items for Child 2 :
Child 3 Name:
Child 3 Age:
Child 3 Gender
Clear selection
Child 3 Clothing Size
Please list desired items for Child 3 :
Child 4 Name:
Child 4 Age:
Child 4 Gender
Clear selection
Child 4 Clothing Size
Please list desired items for Child 4 :
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