Monthly pantry registration

JavaScript tidak didayakan dalam penyemak imbas anda, jadi fail ini tidak boleh dibuka. Dayakan dan muatkan semula.

Monthly pantry registration

We are working on making sure we have enough supplies for everyone.
Please complete our pre-event registration form to help us plan for the day.

We look forward to seeing you on the 3rd Sat. of the month from 10am - 12pm!

Log masuk ke Google untuk menyimpan kemajuan anda. Ketahui lebih lanjut

E-mel *

Is this your first time visiting the pantry? *

YES

Diperlukan

Your First Name *

Your Last Name *

Gender *

MALE

FEMALE

Other

Date of Birth *

TTTT

Address: *

City *

Zip Code *

Phone number: *

Income *

$0- $10,000

$10,000-$20,000

$20,000-$40,000

Ethnicity *

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Lain-lain:

If you need Diapers what size of diapers do you need? *

SIZE 1

SIZE 2

SIZE 3

SIZE 4

SIZE 5

SIZE 6

NONE

Check all items you need.

Shampoo 2&1

Body wash / bar soap

Toothbrush & Toothpaste

Men's Deodorant

Women's Deodorant

Laundry detergent

Toilet paper

Lain-lain:

Do you need Female Products? *

Pads

Tampons

NONE

List ages of all household members *

List genders of all household members *

I acknowledge and understand that I am receiving products from Indy Hygiene Hub willingly and of my own accord. I hereby declare that I assume full responsibility for the use and consequences of these products. I recognize that Indy Hygiene Hub cannot be held liable for any issues, damages, or consequences that may arise from the use, misuse, or any other circumstances related to these products.

I am aware that Indy Hygiene Hub has provided these products without any coercion or pressure, and I absolve them of any responsibility for the outcome of my choice to use these products. I understand that the products are provided without any warranties or guarantees, and I agree to use them at my own risk.

By accepting these products, I release Indy Hygiene Hub, its employees, representatives, Board of Directors and affiliates from any claims, demands, liabilities, or actions that may arise in connection with the use of these products. I confirm that I have read and understood this disclaimer, and I willingly accept the products with the understanding that I am solely responsible for their use and any consequences that may result. *

I accept

I do NOT accept

Diperlukan

We would love to hear what this means to receive hygiene items from Indy Hygiene Hub.

Hantarkan saya salinan jawapan saya.

Serah

Kosongkan borang

Jangan sekali-kali serahkan kata laluan melalui Borang Google.

reCAPTCHA

Privasi Syarat

Borang ini telah dibuat dalam indyhygienehub.org. Laporkan Penyalahgunaan

Borang