PLEASE COMPLETE ALL BLANKS ON THIS FORM TO THE BEST OF YOUR ABILITY.
No Relief Assistance will be provided without completing this form either here online or by completing same at a one-on-one remote interview.
Alamo Resource Conservation & Development Area Inc.
Senior Assistance Program 2021 Registration Form
All entries marked with an ** must be completed.
Full Name of Head of Household **
Provide your complete current PHYSICAL address below as follows: **
City, State, Zip
Press RESET to clear all Entries and start over.
Provide Local Contact: (Next of Kin) **
City, State, Zip
Cell Phone: (XXX) XXX-XXXX **
Please check preferred form of contact **
Please list AGE and FIRST NAME of each Adult and Child in your Family **
Do you want to allow photos and quotes from your family to be used in publications, web or social media? **
Please LIST your top FIVE TOP needs from 1 to 5 with one being your biggest need at this time. (examples: Food, clothing, gas, shoes, prepared foods, medical, diapers, Poise or depends, and more.**
Provide us with a note about your experiences during this COVID-19 Pandemic. Please explain your needs also. Your note will help to determine the assisstance we may provide and may be used on the web and in publications, if you have provided permission. **
By SUBMITTING THIS ONLINE FORM, you indicate that all information on this form is true and factual. You also agree to sign a Statement of Release of Liability and to provide us with a proper ID in the form of a drivers license or other form of picture ID when we meet for a one-on-one Relief Distribution.
Press SUBMIT to enter your REGISTRATION. All entries are final.
Upon Submission the form is automatically sent to email@example.com, Thank you for your Application.
Alamo RC&D Area Inc.
215 W. Bandera Rd. Suite 114-456
Boerne, Texas 78006
Serving Central Texas as an IRS Designated 501(c)(3) nonprofit organization. All donations are tax deductable as per current tax law.
Current AGE &
Date of Birth**
Please Provide MONTHLY INCOME per household. **