Membership Form

Personal Information

Full Name(Required)

First Last

National ID No.(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Gender(Required)

Your Email Address(Required)

Your Mobile(Required)

Residential Information

Your Address

Street Address Address Line 2 City ZIP Code

Type of Residence(Required)

Ownership Status(Required)

Household(Required)

No. of People in Household

Employment Information

Name of Employer

Type of Employment(Required)

Monthly Gross Income in KES

Health Information

Disabilities

If any, please specify

Pre-existing Medical Conditions

Current Medications

Mental Health Status

Social Information

Experience with Traumatic Events

Type and brief description

Substance Use

Type and frequency

Community and Social Support

Are you receiving any other form of aid?(Required)

Government, other NGOs, etc.

Do you have access to clean water and sanitation facilities?(Required)

Are your children (if any) attending school?(Required)

Needs and Priorities

What are your most urgent needs?(Required)

Food

Shelter

Medical Assistance

Education

Employment

What skills or resources do you currently lack that could improve your situation?(Required)

Feedback and Suggestions

How can our organization better serve you?(Required)

Have you previously interacted with our services? If so, what was your experience?(Required)

Vocational Training

Interests and Skills(Required)

Do you have any prior experience in beekeeping, sewing, carpet making, etc.?

Availability for Training(Required)

Days and time you can attend

Education Level(Required)

Willingness to Travel for Training(Required)

Distance you are willing to travel

Access to Tools and Resources(Required)

Do you have access to any tools or materials related to the training?

Preferred Training Method(Required)

Healthcare

Eye Clinic

Current Vision Issues(Required)

Specific problems like cataracts, glaucoma, etc

Vision Health History(Required)

Any previous eye treatments, surgeries, or diagnoses

Access to Eye Care Services(Required)

Have you had access to eye care before?

Impact of Vision Issues on Daily Life(Required)

How vision problems affect your ability to work or perform daily tasks

Environmental Programs

Tree Planting

Knowledge of Environmental Conservation(Required)

Any prior involvement in environmental activities

Willingness to Participate in Tree Planting(Required)

Availability for Participation(Required)

Days and times you can help

Access to Land(Required)

Do you have access to land where trees can be planted?

General

Language Proficiency(Required)

Primary language spoken, literacy levels

Access to Technology(Required)

Smartphone

Computer

Internet

No access

Do you have access to a smartphone, computer, internet?)

Community Involvement(Required)

Are you involved in any community groups or local organizations?

Community Involment: specify which organisation(Required)

Transportation Needs(Required)

Do you have reliable transportation to attend training, clinics, or events?

Consent

I agree to the privacy policy.

Comments

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