Please enable JavaScript in your browser to complete this form.Tell Us About YourselfYour Name *FirstLastYour Phone *Your Email *EmailConfirm EmailTo ensure your needs are met, may one of our volunteers contact you with resources? *_ Yes, please email me resources_ No, I do not need further resourcesWarrior KitsHow are you connected to the person or group receiving the Warrior Kit? *_ I am requesting this kit for myself_ I am an advocate, therapist, or social worker_ I am a family member, ally, or part of their support circle_ I am a member of the clergy or a spiritual leader_ Something else... [Could you share a little bit about your connection below?]PLEASE NOTE this helps us understand how best to support the hand-offIf you selected "Something else," could you share a little bit about your connection?Who are the Warrior Kits going to? *Choose oneAn individual or familyA non-profit or community groupA business or workplaceOrganization NameOrganization Website / URL: *Organization Email: *Organization Phone Number:Organization Address:Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeThis Organization Works with Survivors of... (check all that apply) *_ Domestic Violence_ Sexual Assault_ Sex Trafficking_ Hate Crimes_ Child Abuse_ Other (please describe below)_ UNKNOWNIf OTHER, please describe:This Organization Works with...(check what applies best) *_ All ages, all genders, all orientations_ All adults (adults, geriatric adults, LGBT+ adults)_ Adults, Teens, children (no geriatric)_ Children (only)_ Children & teens (only)_ Teens (only)_ LGBTQIA2+ teens (only)_ LGBTQIA2+ adults (only)_ Adult females **and those who identify as females** (only)_ Adult males **and those who identify as male** (only)_ Geriatric adults (only)_ LGBTQIA2+ geriatric adults (only)_ Other Specific (please describe below)_ UNKNOWNIf OTHER, please describe:How many Warrior Kits are you asking for? (our ability to fill needs are based on supplies) *Choose12345Other (please describe)If requesting more than 5, please let us know how many [more than 15 will require more time]: *How many Warrior Kits are you requesting? (our ability to fill needs are based on supplies) *Choose151015(describe need below)If your need exceeds 15 Warrior Kits at a time, please describe need: *Organization Needs: Mail or Delivered? *_ Kits Can Be Delivered to Organization with Scheduled Appointment_ Kits Must Be Shipped [this may cause a delay based on S&H fees we need to cover]_ UNKNOWNCan the Warrior Kits Be Delivered or Need to Be Shipped? *_ Kit(s) can be delivered by driver to you_ Kit(s) can be delivered by driver to a third party who is connected to the survivor(s)_ Kit(s) need to be shipped [this may cause a delay based on S&H fees we need to cover]_ UNKNOWNWho Should the Kits Be Addressed to? *FirstLastWhat Address Should the Kits Be Shipped to? *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeIs Third Party Aware We Will Be Contacting Them? (required) *[YES] They are awaiting contact from a KAD representative[NO] Due to privacy policies, we cannot contact third parties without their prior consent. Please confirm their consent before submitting this form.Name of Third Party *FirstLastEmail of Third Party *Phone # of Third Party *Address of Third Party *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodePhoneSubmit
