GRACE Family Service Request

GRACE Family Service Request
Today's Date

MonthDayYear
Date
Name

First NameMiddle NameLast Name
Primary Phone Number
Please enter a valid phone number.
Phone Type

CellHomeWork
Secondary Phone Number
Please enter a valid phone number.
Phone Type

CellHomeWork
Preferred Contact Method

PhoneEmailText
Email
example@example.com
Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please tell us about all the people in your household:

	Full Name	Relationship	Date of Birth	Monthly Income
Member 1
Member 2
Member 3
Member 4
Member 5
Member 6

Referred By:

Social ServicesThe HavenFriend/RelativeWebsiteOther
What is your request?

Household Goods - Bag (every 6 months)Large Household Items (Appliance)Large Household Items (Furniture)Assistance with Home MaintenanceAssistance with Yard Work
Describe your Request
If request is for donated goods, can you arrange to pick up your items?

YesNo
Directions (if applicable)
Would you be willing to be a volunteer for GRACE?

YesNo
Any Additional Comments
Would you like a referral to one or more of the following? Check all that apply.

BudgetingDepartment of Rehab ServicesFamily ServicesFeeding Greene Food PantryGDSS - Social ServicesGreene Care ClinicGreene Health Dept.JABALandlords ListLions ClubRegion TenSalvation ArmySheriff's DeptSkyline CAPTuesday's Table
DISCLAIMER FOR FAMILY SERVICE REQUESTS

Greene Alliance of Church/Community Efforts, Inc. (GRACE) is a non-profit 501(c)(3) organization. Our Mission is: "We identify and create resources from GRACE, churches and the community to provide compassionate and transformative assistance to those who express a need in Greene County."

GRACE’s ability to provide the household goods and/or services requested is dependent upon donations received from the community and the availability of our ALL VOLUNTEER network to deliver the goods donated or to perform the services requested. There is no guarantee that the household item(s) you have requested will be donated to GRACE or that the services requested will be provided. We do, however, solicit donations and help with services from our community of supporters in an effort to meet the needs requested. Often requests for some household items will require long waits (e.g., washers and dryers, dressers). Also, service requests may take some time to coordinate and fill as well.

As donated household items are received, requests will be filled on a first-come, first-served basis. GRACE volunteers MUST BE ABLE TO REACH YOU to deliver the items requested or arrange for services requested. If your contact information or address changes, please call the GRACE office at 434-985-6792 and report any changes. Also, please make every effort to keep your telephone service active. If you are next in line to receive a specific item or service and our volunteers cannot reach you, the next family on the waiting list will receive the item or service.
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GRACE Family Service Request

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