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PKCC New Client Request
(All Household Members must show ID or Birth Certificate)
Personal Information
Name
*
First Name
Last Name
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Male
Female
Decline to Answer
Other
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
*
Black/African American
American Indian/Alaska Native
Asian (Not Cambodian)
Brazilian or Portuguese
Cambodian
Hispanic/Latino
Middle Eastern
Biracial
Decline to Answer
White/Caucasian
Other
Health Insurance
*
MassHealth
Private Insurance
None
I would like help obtaining coverage
Do you have an ID, Drivers License, or Birth Certificate?
*
Please Select
Yes
No
No, and would like help obtaining them
Decline to Answer
Photo ID, Drivers License, Birth Certificate, etc.
Language (Primary)
*
English
French
Khmer
Portuguese
Spanish
Other
Language (Secondary)
English
French
Khmer
Portuguese
Spanish
Other
Total in Household
Please include yourself in the count. Your information is for Project Kompass use only and will not be shared with any outside agency or organization.
# of Adults (18-64)
*
Please enter 0 if not applicable. ID/birth certificate needed to access community closet.
# of Children (Under 18)
*
Please enter 0 if not applicable. ID/birth certificate needed to access community closet.
# of Seniors (65+)
*
Please enter 0 if not applicable. ID/birth certificate needed to access community closet.
Total # of Female/Girls
*
Please enter 0 if not applicable. ID/birth certificate needed to access community closet.
Total # of Male/Boys
*
Please enter 0 if not applicable. ID/birth certificate needed to access community closet.
Family Member Information (Name, Relationship, DOB, Gender):
*
Please enter N/A if not applicable.
Is anyone in your household a veteran?
*
Yes
No
Is anyone in your household disabled?
*
Yes
No
Is anyone in your household part of the LGBTQ+ community?
*
Yes
No
Prefer not to answer
Emergency Contact Information
Name
First Name
Last Name
Phone Number
Relationship
What can we assist you with? (Select all that apply)
*
Food
Clothing
Diapers/Baby Essentials
Personal Hygiene Items
Housing Application Assistance
Need an ID / birth certificate
Wish Project Referral
Mental Health or Counseling Support
Recovery or Addiction Support
Other
Do you or any of your family members have food allergies?
*
Yes
No
Please list all food allergies
Is there anything else you would like to share with us?
I understand that I must provide a copy of my ID/Birth Certificate for each family member.
*
Yes, I understand
I need help to obtain an ID/Birth Certificate
Photo / Media Consent
*
YES – I give Project Kompass permission to use photos, video, or audio of me for documentation, social media, promotions, or fundraising. No identifying information will be shared without my permission.
NO – I do not give permission for Project Kompass to take or use photos, video, or audio of me for any purpose.
Submit
Should be Empty: