All submissions will be prioritized based on the information provided on questionnaire.
Name *
E-Mail *
Phone Number *
Address *
Do you currently have a water connection? *
How many people currently live in your household? (NOTE: Please list the members of your household and their ages. If they have been tested for Lead and found positive please provide the number associated with their level of exposure given to you by the doctor who conducted the test) *
Is anyone in your household disabled? (NOTE: If yes please describe your family’s medical situation) *
Is anyone in your household home-bound or immobile? (NOTE: If yes please describe) *
Does anyone in your household have special needs? (NOTE: If yes please describe) *
Is anyone in your household undocumented? *
Do you have a vehicle? *
Please give us additional information that can help us prioritize your needs?
Number of people in your household? *
Best time to reach you? *
This document is intended for the purpose of determining priority placement on distribution list and may contain confidential and/or privileged material. Any review, retransmission, copying, dissemination or other use of this information by persons or entities other than the intended recipient is prohibited by law. If you received this in error, please contact the sender, forward this document to BOTWdelivery@gmail.com then delete the material from any computer. The contents of this document are under the sole ownership of Beats Rhymes & Relief 501c3.
2 + 5 = ?Please prove that you are human by solving the equation *
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