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Birthday Outreach Sign Up Form
Fill in to join us on our birthday outreach event on your birthday month
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* Indicates required question
Email
*
Your email
Why do you wish to join us for the outreach?
*
To give back
To make a difference
To change a life
It's cool
Its passion
Other:
Required
Please refer friends to share the joy of giving. Provide email and names below to gift them an outreach on their birthday.
*
Your answer
Which event, are you signing up for?
Your answer
If employed, who is your current employer?
*
Your answer
Email
*
Your answer
I understand terms and condition
*
Yes
Confirm your transport: Pay KES1500 to MPESA on pay bill number 773626
*
I will MPESA my transport
I will pay transport in cash when I deliver my donation
Mobile Phone Number
*
Your answer
Occupational Status
*
Employed
Self - Employed
Student
Other:
Transport payment confirmation text: Copy the MPESA transaction message below
*
Your answer
Where are you based? (Location)
*
Nairobi
Outside Nairobi
Other:
Donations Drop off time
*
Time
:
AM
PM
Donation Drop off Date
*
Drop off location: Landmark Plaza 13th Floor
MM
/
DD
/
YYYY
Have you been to an outreach event before?
*
Yes
No
Other:
How will donating these items make you feel?
*
Least satisfied
1
2
3
4
5
Very satisfied
Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
How did you learn about us?
Social Media
Networking Event
Referral
Website
Other:
What items will you donate on this outreach
*
Flour - Maize or Whet
Toiletries - Bathing soap/ Tissues/ Toothpaste/ Toothbrush
Cooking - Cooking oil, vegetables, green grams, lentils/beans
Kitchen - Plates, pans, cups, cooking gas
Necessities - Diapers/ Adult Pads
Other:
Required
A copy of your responses will be emailed to the address you provided.
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