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FACTS ENROLLMENT FORM
Enrollment for Faith Based/Community Institutions & Distribution of PPE KITS. Call: (216) 924-3342
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Date
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MM
/
DD
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YYYY
Name Institution below:
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Your answer
Ward:
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Your answer
Address below:
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Your answer
List Contact Person & Phone Number:
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Your answer
Email Address:
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Your answer
Number of Member at Service:
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Your answer
Days of Service:
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Your answer
Please check PPE item(s) requested for your congregation members attending physical services. (check all that apply)
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Contact Thereometer
KN-95 Masks
D-19 Hand Sanitizer
Required
Please select the sizes of the KN-95 masks needed.
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S
M
L
XL
Date & Time to Receive PPE KITS:
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Your answer
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