Please Introduce Yourself *

First Name

Last Name

Best Phone Number To Reach You At *

Please provide us with the best number to contact you at.

(###)

###

####

Can We Text You At This Number? *

Yes or No

Yes

No

Address *

Where Are You Currently Residing?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What Type of Items Do You Seek? *

Please only check off what you need right now. We do not guarantee items and only provide what we currently have on hand. If your emergency was due to a fire or a natural disaster we will make arrangements to get what is needed.

Diapers

Baby Gear

Clothes

Feminine Hygiene Kits

Food

Furniture

Shelter

Back to School Supplies

School Uniform

Other

I UNDERSTAND THE FOLLOWING *

by providing my personal information to The BCA Hub it will not be sold to another party. I understand that I will have to show proof of my driver's license or state ID. I understand I will have my picture taken to create a Hub File Number. I understand that giving false information to The BCA Hub will disqualify me or anyone in my application for assistance. I understand that The BCA Hub is a first-come-first-served organization and that they do not hold items. I understand that once I am verified with The BCA Hub I will be given access to special events at a lower rate than non-hub members in a 6-month calender year from my start date. I understand that The BCA Hub will check with other organizations to see if I am registered at other locations asking for the same assistance. I understand Organization Jumping will disqualify me and anyone on my application. I understand that the information I provide to The BCA Hub will be crossed checked with other organizations, housing verification, employment verification, townships, and state programs whether they are private or public, and my social media accounts. I understand that I must provide birth certificates for each child I register at The BCA Hub. I understand that I will have to show proof of my emergency. I understand that I will not take ANY items given to me or my family from The BCA Hub and sell them whether to a private or public party. I understand that should I be caught selling ANY items from The BCA Hub it will be considered theft by deception and falsely portraying to be in a state of emergency when truly I am not. I understand should I be caught then The BCA Hub will turn my information over to the proper authority for criminal charges. I understand that if I miss my appointment I am automatically disqualified unless I can show proof of a medical reason.

I Understand and Agree To All The Rules

I changed my mind and will pass my items to another person in need.