Client Intake Form

BDUSA in Pennsylvania

Mon - Fri 10AM - 5PM
+1(412)-932-3668 / +1(412) 290-8270

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bdusainpennsylvania.com

Membership Application Form | State of Pennsylvania

BDUSA | BURUNDIAN DIASPORA IN THE UNITED STATES OF AMERICA

Member’s Name(Required)

First

Member(Required)

Renewing Member

New Member

Mobile Number:(Required)

Home Phone:(Required)

Mailing Address:(Required)

Mailing Address City State / Province / Region ZIP / Postal Code

Emergency Contact Name(Required)

Name

Mobile Number(Required)

Home Phone(Required)

Mailing Address(Required)

Email Address(Required)

Married/Single(Required)

If Married Spouse Name(Required)

(Required)

City State / Province / Region ZIP / Postal Code

MEMBERSHIP PAYMENT

MEMBERSHIP FEE(Required)

$20.00 Lifetime membership/subscription for Single (Skip the next section if you selected this option)

$40.00 Lifetime membership/subscription for Family

Receiver Ofﬁcer(Required)

Receiver Ofﬁcer

Signature(Required)

Print Name(Required)

Print Name

Paid Online on(Required)

Paid Online on

Membership Date(Required)

MM slash DD slash YYYY

MEMBERSHIP FAMILY MEMBERS UNDER EIGHTEEN

Details(Required)

Full name

Date of Birth

Relation (S/D)

School Attended

** For our records, please provide a document that proves your child is under eighteen. The school she/he attends can provide a certiﬁcate of attendance.

CERTIFICATION - AGREEMENT(Required)

I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it.

CERTIFICATION - AGREEMENT(Required)

I declare to have received a copy of the statutes (and possibly of the internal rules) of the association, of which I was able to take knowledge. I declare to commit myself to respect all the obligations of the members of the association which appear there.

Signature(Required)

Print Name(Required)

Print Name

MATRICULATED UNDER REFERENCE

BDUSA IN PA/REF 2022 – 2023

Remember to ask a copy of this Membership Form from the Registering Ofﬁcer for your records

Name(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

County(Required)

Email(Required)

Phone(Required)

Family Sources of Income:(Required)

Employed

Self-employed

Retirement

Unemployment

Worker’s Comp

Disability

No income

Other

(mark all that apply)

Are there any other needs your household currently has?(Required)

-Parenting Education

-Parents as Teachers home visits

-Early-childhood resources

-Adult Education / GED

-Support with nutrition and exercise

-Food

-Workforce Assistance

-Energy / Utility bill assistance

-Access to medical care

(mark all that apply)

Referral To

Name(Required)

First Last

Email(Required)

Referred By

Name(Required)

First Last

Email(Required)

Phone(Required)

Signature of client(Required)

parent or guardian(Required)

Date(Required)

MM slash DD slash YYYY

Get In Touch

+1(412)-932-3668 +1(412) 290-8270

bdusapennsylvania@gmail.com

1429 Chicago St Pittsburgh, PA 15214

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July 29, 2022

Membership Application Form | State of Pennsylvania

BDUSA | BURUNDIAN DIASPORA IN THE UNITED STATES OF AMERICA

MEMBERSHIP PAYMENT

MEMBERSHIP FAMILY MEMBERS UNDER EIGHTEEN

MATRICULATED UNDER REFERENCE

BDUSA IN PA/REF 2022 – 2023