Requisition Supplies/Materials Form

Reproductive Justice Needs Assessment

A Collabrative Community Initiative by TKO Society & Yellow Hammer Fund
Notice: Due to limited funding we prioritize direct support requests from Alabama TGNC and LGBQ residents. We will accept requests from surrounding southern states on a case by case situation.

For more information about The Knights & Orchids Society or Yellow Hammer Fund, please visit our website (www.tkosociety.com) or social media pages.
Demographic Information
Today's Date *

Month Day Year
Preferred Name: (How do you want to be addressed?) *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Pronoun *

She/ Her He/Him They/them Zi/Zir
What is your sexual orientation?

Straight Same Gender Loving Bi-Sexual Do not wish to disclose
What is your Race/Ethnicity?

African American Caucasian Latin(x) Do not wish to disclose
How do you identify?

Cisgender Woman Cisgender Man Trans Feminine Trans/Non Binary/GNC Trans Masculine
Age
Address *

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Select Branch:
Submitted By:
Household Information
Number of people in the family?
2. How many Military Veterans?

How many of each age group is in the household?

Satisfied

0-12

13-18

19-29

30-39

40-49

50-59

60-69

70 and up

Please check one or more boxes below:

My household receives food stamps. My household receives SSI. My household has special circumstance. (Fire, Flood, Homeless etc.) My household is below poverty level. (unemployed, low-income, etc.) I am not safe/experiencing violence/domestic violence. None of these apply to my household.
Are you currently employed?

Yes No
I would like to receive a special care package while supplies last. (TGNC Folks only)

Yes, Please. No thank you.
Would you like more information about additional services offered?

Yes, Please. No thank you.

YOU MADE IT!

Thanks for taking the time to submit this needs assessment for us. These assessments help us figue out which services and resources the community values and helps us better provide the things our community wants. Feel free to go back through and check your answers or you can hit submit now.
Should be Empty:

Reproductive Justice Needs Assessment