JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
FACTS ENROLLMENT FORM
Enrollment for Faith Based/Community Institutions & Distribution of PPE KITS. Call: (216) 924-3342
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Date
*
MM
/
DD
/
YYYY
Name Institution below:
*
Your answer
Ward:
*
Your answer
Address below:
*
Your answer
List Contact Person & Phone Number:
*
Your answer
Email Address:
*
Your answer
Number of Member at Service:
*
Your answer
Days of Service:
*
Your answer
Please check PPE item(s) requested for your congregation members attending physical services. (check all that apply)
*
Contact Thereometer
KN-95 Masks
D-19 Hand Sanitizer
Required
Please select the sizes of the KN-95 masks needed.
*
S
M
L
XL
Date & Time to Receive PPE KITS:
*
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. -
Terms of Service
-
Privacy Policy
Does this form look suspicious?
Report
Forms
Help and feedback
Contact form owner
Help Forms improve
Report