Please enable JavaScript in your browser to complete this form.Requestor's Name *FirstLastRequestor's Email *EmailConfirm EmailRequestor's Phone *How Is the Requestor Connected to the Individual(s) or Organization Receiving the Warrior Kit(s)? *SelfAdvocate / Therapist / Social WorkerEmployed by the Nonprofit Requesting forFamily / Ally / Support personClergy or Spiritual LeaderOther (please describe below)We want to make sure you have the resources you need. Can one of our volunteers contact you to make sure your needs are met? *Yes, a KAD confidential volunteer can contact me at the above infoNo, I would prefer to be contacted by a KAD staff member (this will take a longer time and is dependent on our staff's availability)If OTHER, please describe how requestor is connected:Request for an Individual or an Organization? *ChooseIndividual(s)OrganizationWhat Is the Name of the Organization?What Is the Organization's Website / URL? *What Is the Contact Email for This Organization? *What Is the Contact Phone Number for the Organization?What Is the Organization's Address?Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeThis Organization Works with Survivors of... (check all that apply) *Domestic ViolenceSexual AssaultSex TraffickingHate CrimesChild AbuseOther (please describe below)UNKNOWNIf OTHER, please describe:This Organization Works with...(check what applies best) *ChildrenAdult Males (and those who identify as male)Adult Females (and those who identify as females)All adultsAdults and ChildrenGeriatricOther Specific (please describe below)UNKNOWNIf OTHER, please describe:How Many Warrior Kits Are Requested? (if multiple households, please make separate requests) *Choose12345Other (please describe)If OTHER, please let us know how many Warrior Kits you are requesting (multiple households need more than one request): *How Many Warrior Kits Is the Organization Requesting? (our ability to fill needs are based on supplies) *Choose15101520253031+ (describe need below)If the Need Is Greater Than 30 Warrior Kits, please describe need: *Organization Needs: Mail or Delivered? *Kits Can Be Delivered to Organization with Scheduled AppointmentKits Must Be ShippedUNKNOWNCan the Warrior Kits Be Delivered or Need to Be Shipped? *Kit(s) can be delivered to requestorKit(s) can be delivered to a third party who is connected to the survivor(s)Kit(s) need to be shipped UNKNOWNWho Should the Kits Be Addressed to? *FirstLastWhat Address Should the Kits Be Shipped to? *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict 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 KADNo (we at KAD are unable to reach out to third parties that have not been notified by requestor)Name of Third Party *FirstLastEmail of Third Party *Phone # of Third Party *Address of Third Party *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeWarrior Kits Are Always Available to Those Who Need Them, Without Charge, However If You Are Able to Donate, Let Us Know:I want to sponsor a Warrior Kit(s)Our organization wants to sponsor a Warrior Kit(s)This Warrior Kit is for me (please do NOT sponsor your own Kit; let it be a blessing to you)I am unable to donate at this time (this is absolutely fine)NameSubmit
