Request General Assistance - Community Help

Assistance Request Form

Thank you for reaching out. Please complete this form so we can better understand your needs. All information will be kept confidential.

Important: Advance Notice Required

Please submit your request at least 24-48 hours in advance. Requests submitted with less notice may not be able to be fulfilled. This allows us time to properly review and coordinate your assistance.

Personal Information

First and Last Name *

Address *

Zip Code *

Phone Number *

Email *

Assistance Information

Please describe the type of assistance you are requesting *

Is this request urgent? *

Yes

Preferred way to be contacted *

Phone

Mail

Other

Do you have any special circumstances we should know about? *

Are you currently working with any other organizations or programs? *

Yes

Agreement

I certify that the information provided is true to the best of my knowledge.

I understand this form is a request for assistance and does not guarantee services.

Signature (Type your full name) *

Date *

* Indicates required field. All information is kept confidential.