Relief Distribution Intake Form
Please fill out this form and click submit.
Completing this form will ensure further future needed assistance.
Name (Nombre)
*
Address
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Email (Correo Electronico)
*
This address will receive a confirmation email
Phone (Telefono)
*
Age Group
*
Please select all that apply.
Under 18
Under 22
23-35
36-49
50-65
66-75
76 and over
You Need: ( Que Necesita:)
*
Please select all that apply.
Food (Comida)
Clothes (Ropa)
Toiletries (artículos de aseo)
None of These
Others: Specify (Otra necesidades: Especificar
Family Size ( ¿Cuántos son en tu familia?
*
How were you affected by the fires?
*
How did you hear about us? (Como te enteraste de nosotros?)
*
Please select all that apply.
Nextdoor
Facebook
Youtube
Ring Neighborhood
Flyers (Volantes)
Friend (amigo/amiga)
Drove/Walk by
Others
Do you want to hear updates from Pasadena Seventh-day Adventist Church ? ( Quieres recibir noticias de eventos en Iglesia Adventista de Pasadena?)
*
Please select one option.
YES (Si)
NO
Updates from Community Service only ( Noticias solo del servicio comunitario
Select Option
YES (Si)
NO
Updates from Community Service only ( Noticias solo del servicio comunitario
In addition to our community services, would you be interested in what our church offers? Please check all that apply.
Please select one option.
Activities for Families
Activities for men
Activities for women
Activities for Singles
Activities for Youth & Young Adults
Activities for children
Activities for Married Couples
Healthy Living, Exercise, and Disease Prevention
Cooking classes
Financial Seminars
Stop Smoking Seminars
Drug & Alcohol Awareness
Learning about Bible Prophecy and the Times we now living in
None of the above
Do you believe in God?
*
Please select all that apply.
Yes
No
Unsure
Do you believe Jesus is coming again?
Please select all that apply.
Yes
No
Unsure
If you had the opportunity would you like to study the Bible
Please select one option.
Teacher to come to your home
Teacher to drop off materials at your home
Small study group at this church
By Mail
By Zoom Conference
Online on your own time
I would not like to study at this time
Can We Pray for You? What is your prayer request?
Submit
Description
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