Intake Form | African Society Foundation Inc.

Full Name

First

Last

Date of Birth*

Postal Address

Village / Location*

County / Province

County / Province*

C/O Telephone Number*

C/O Email address*

Upload Photos or ID Copy*

Number of household members under age of 10*

Number of household members under age 10-18*

Number of household members under age 18-65*

Number of household members under age 65+*

Do you have any living family members or relatives? If so, please provide their names and contact information.

Do you have food at home? If not, what do you eat regularly?*

If you have some food, how many days before you run out?*

Do you need medical care?*

Do you have a disability?*

When was your last Doctor's or Hospital Visit?*

Do you have transportation to the nearby clinic or hospital?*

Are you or anyone in your household employed or gainfully working?*

Do you or anyone in your household receive a pension or other retirement benefits?*

Do you or anyone in your household receive other government assistance? retirement benefits?*

Do you have family, neighbors, or friends who visit you?*

Do you attend or participate in any local community events such as Religious Events, Health Fairs, Local Festivals, etc.)?*

This field should be left blank