Barnabas Center Information Sheet



Household Member 1

Household Member 2

Household Member 3

Household Member 4

Household Member 5

This information is needed for our records. We do not anticipate any problems, but you should examine the products you receive before use. By your signature, you release Park Avenue Church of Christ from any liability resulting from conditions which might arise from use of these donated products. By signing this you give us the right to share this information with other agencies.