Healing Hearts Foundation Assistance Application Form
About the Healing Hearts Foundation Food Drive: The Healing Hearts Foundation, an initiative by Banks & Co. Therapy, is dedicated to supporting families affected by the recent severe weather in the DFW area. We aim to financial assistance to 4 families facing food scarcity and financial hardship. Selected families will receive financial aid via gift cards based on their needs. Please fill out this form with accurate information to help us assess your situation and provide the best possible assistance.
Personal Information
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Family Information
Number of Family Members:
*
Ages of Family Members:
*
Current Situation
Describe how the recent severe weather has impacted your family:
*
Are you currently facing food scarcity?
*
Yes
No
Do you lack the funds to secure more food?
*
Yes
No
Financial Information
Monthly Household Income:
*
Monthly Household Expenses:
*
Any additional financial assistance you are receiving (e.g., SNAP, WIC, unemployment benefits):
Additional Information
Do you have access to cooking facilities?
*
Yes
No
What type of assistance would be most helpful to your family? (e.g., groceries, prepared meals, financial aid)
Any other information that would help us understand your needs:
Documentation
Proof of Residency: (e.g., utility bill, lease agreement)
*
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Proof of Income: (e.g., pay stubs, tax returns, benefits statement)
*
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Any other relevant documentation:
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of
Consent
I consent to my information being used solely for the purposes of this assistance program:
(Yes/No)
*
Signature
*
Submit
Should be Empty: