Giving to the Nations – devoted to advancing the lives of others
Please complete the Intake Form online or download, print and return to us through email or US Mail (instructions are on the form).
Downloads: Intake Form | Product List
OFFICE USE ONLY
Date : _______________ | Request Type: Individual | Event / Name ____________________________
New Client Certification | Client Recertification | Client Number: ____________________
Processed By: _____
NOTE: These questions do not determine your ability to receive services. This information is collected for tracking the need for future services and for obtaining additional funding to support our programs.
How many people live in your house in the following age/gender groups and indicate how many are male or female
PETS - Please enter a number for each.
Please select all that apply*
These questions do not determine your ability to receive services.
Please list each family member receiving income.
I certify that I am a member of the household listed above, 18 years of age or older, and certify that all information regarding my household is true to the best of my knowledge. I also designate the following person(s) as an authorized representative(s) of my household and certify that their information is correct to the best of my knowledge. Authorized representative(s) is/are able to pick up product for client until re-certification is necessary.
This section is only necessary if someone will be picking up product for you.
If you will be picking up for yourself, please leave this blank.
Name of Authorized Representative(s)
Authorized Representative(s) Address/Phone
(office use only)
Pick up Person: _______________________________________________________ Pick up Date: __________________
Giving to the Nations is an organization devoted to the assembling of all those with giving hearts to advance the lives of others, by organizing the compassionate power in people’s lives locally and around the world to advance the common good.
4003 Durand Avenue, Suite 5ARacine, WI 53405
Copyright © 2020 Giving to The Nations by Focus Media. All Rights Reserved.