EmailMeForm
FULL NAME
*
First
Last
DATE OF BIRTH
*
MM
/
DD
/
YYYY
TELEPHONE
*
###
-
###
-
####
EMAIL
*
This email address will be added to contact List
ADDRESS
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
If needing Food & Hygiene Bank please fill out for every member of the household:
FIRST NAME
LAST NAME
DATE OF BIRTH
RELATIONSHIP TO APPLICANT (E.G. SPOUSE, CHILD, ROOM-MATE)
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
I AM IN NEED OR INTERESTED IN THE FOLLOWING SERVICES THAT PELHAM CARES PROVIDES:
*
Back-to-School Program
Birthday Program
Budget Counselling
Christmas Hampers
Christmas Toys
Emergency Help
Food & Hygiene Bank
Income Tax
Information & Referrals
Thanksgiving Hampers
Transportation – Medical Drive Program
Utility Support Program
Winter Coats
Youth Sport & Recreation Subsidy
After registration, you will be contacted promptly by email or phone to arrange an appointment.
