Give San Diego Emergency Aid Application

Give San Diego Emergency Aid Application
Basic Information

Emergency Aid to help families impacted by the pandemic in purchasing food & hygiene items. Please make sure information is correct so if you do qualify we can deliver the aid to the correct address.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Gender *

Female Male
Phone Number *
Address *

Street Address

Street Address Line 2

City State

Zip Code
Email *
example@example.com

Family Information
How many members are in your family? *
How many members of your family are boys (male under 18 years old)? *
How many members of your family are girls (female under 18 years old)? *
How many members of your family are adult men (male between 18 and 64 years old)? *
How many members of your family are adult women (female between 18 and 64 years old)? *
How many members of your family are old men (male 65 years or older)? *
How many members of your family are old women (female 65 years or older)? *
How many members of your family are disabled (have a physical or mental disability, or are receiving disability insurance)? *
Is your family homeless? *

Yes No
Please explain your situation. And how has COVID 19 affected you and your family? *
Disclaimer

Applications will be disqualified if fraud is discovered. Submitting this application does not mean aid will be granted or approved. Aid is limited and priority is given to families based on their situation. I acknowledge that all the information submitted in this application is correct to the best of your knowledge.
Signature

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Basic Information