3CoC 2025 PIT Supply Form

Three County CoC PIT Count - Supply Request Form

For participating providers/volunteers January 2025
Instructions:

Organizations that are CoC partners (Case Conferencing, Subrecipient, other Community Organizations) should only submit one request per team/organization when possible.

Before completing this form, ensure that you have:
- Completed training and reviewed instructions on the Three County CoC's PIT Count Webpage
- Thoughtfully considered your plan to complete outreach or suvey persons you provide services to
- Estimated how many people you expect to survey between January 30th through February 5th
Contact information shared in this form will only be used for PIT Count communication purposes.

If you have questions, please contact Natalie Burtzos nburtzos@communityaction.us

Contact Information
Are you requesting items as an agency representative or as an individual volunteer?*
Name*

First NameLast Name
Email*
If you are part of an agency, please use your agency email address
Phone Number*
Please enter a valid phone number.
Can you be reached by text for coordinating pick up/drop off at the above phone number?*

YesNo
Did you complete the 2025 PIT Count Training before completing this form?*

YesNo
Counties you plan to survey (check all that apply)*

BerkshireFranklinHampshire

Request for Materials/Items
Number of Persons you expect to survey/count*
Would you like to include printed materials (surveys, resource guides, etc.) as part of your request?*

YesNo, I am printing my own copies
Request for items to hand out

Please indicate from each drop down the count of any items you are requesting for PIT Count outreach
Gift Cards Requested
Hats Requested
Gloves Requested
Socks Requested
Handwarmer pairs Requested
Toe-warmer pairs Requested
Ear-warmers/Headbands Requested
ChapSticks Requested
Sweatshirts Requested

Getting Requested Items

Plan to pick up or receive items between Monday January 20th through Tuesday January 28th
How would you like to receive the items?*

Pick up from Three County CoC Office in Greenfield (address and instructions will be sent via email)Request for Items to be dropped off at a locationOther

Plan to pick up or receive the items between Tuesday January 21st and Tuesday January 28th

Please describe what days, times, location, and any other information needed to facilitate your pick up/drop off:*
Should be Empty:

Three County CoC PIT Count - Supply Request Form