Recipients – The ReCARES Network

Recipients

Contact Information

Thank you for tapping into The ReCARES Network!
Any information we collect is for demographic purposes and will support our efforts to secure funds that are needed to continue and improve our services in the community. No individual data will be shared with any funders, partners, stakeholders or volunteers; only aggregate (summary) data may be shared.
Your personal data will remain anonymous. Your name and signature will be required initially to set up a patron account, with a number, for you. The account will incorporate our liability waiver and allow us to serve you more efficiently on return visits without the need to complete a paper form on each visit—saving you time and sparing our environment!

Who are you picking up for?

Myself

Friend/Family

Healthcare Client

My Organization (Bulk)

First Name

Last Name

My Organization(Bulk)

Some description about this section

First Name

Last Name

Name of Organization

Healthcare Worker

Are you here on behalf of a healthcare agency or another patient?

First Name

Last Name

Friend/Family

What is your name?

First Name

Last Name

Agency

Phone Number

Organization Website URL

Client Information

Please provide responses about the end user of the equipment or supplies being recieved.

First Name

Last Name

Age

Description

Quantity

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Race/Ethnicity

Income Level

Preferred Language

What gender do you identify as

Female

Male

Non-Binary

Would Rather Not Say

What gender does your friend/family member identify as?

Female

Male

Non-Binary

Would Rather Not Say

What gender does your patron identify as?

Female

Male

Non-Binary

Would Rather Not Say

What most closely describes your current living situation?

Stable

Transitional

Unhoused

What Insurance do you currently have?

Medicare

Medi-Cal/Medicaid

Employer Sponsored/private

Not insured

What is your reason for coming to ReCARES?

Prefer not to buy new equipment to protect the environment

Items are too expensive and/or not covered by insurance

Takes too long for insurance to cover items

Item Picking Up

What item(s) will be picked up today?

Item	Description	Quantity

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