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Samaritan Relief International Network Inc.
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Intake form
Help us serve you better
Name
*
Email address
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What is your primary concern regarding water access?
Please select at least one option.
Contamination
Availability
Affordability
Infrastructure
Health Risks
Which region are you inquiring about?
Select
North America
South America
Europe
Africa
Asia
Australia
What type of assistance are you seeking?
Please select at least one option.
Information
Funding
Partnerships
Volunteer Opportunities
Advocacy
How did you hear about us?
Select
Social Media
Word of Mouth
Website
Event
What is your organization type?
Select
Non-Profit
Government
Community Group
Individual
For-Profit
Which service or services are you interested in?
Please select at least one option.
Clean water access initiative
Health education workshops
Sustainable water projects
Donations for $150
Follow-up consultation for $100
Additional questions or comments
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