Hygiene Assistance Form

Hygiene Assistance Form

For individuals seeking hygiene support services or supplies
Full Name
Date of Birth

MonthDayYear
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Are you currently experiencing homelessness?*

YesNo
Current Living Situation (check one):*

Unsheltered(street/tent/car)Emergency ShelterTransitional HousingDoubled Up with Friends/FamilyOther
Source of Income (check all that apply):*

EmploymentUnemploymentDisabilitySocial SecurityFood StampsChild SupportNo Income
Required Income Verification Documents
(Please attach or provide one of the following)

Last 2 Pay StubsBenefit Award LetterBank StatementUnemployment StatementFood Stamp Award LetterWritten Statement of No Income
File Upload

Cancelof
Toiletries

Toothbrush& ToothpasteSoap/BodyWashDeodorantShampoo/ConditionerLotionFeminine Hygiene ProductsRazors/Shaving CreamComb/BrushNail Clippers
Clothing& Supplies:

SocksUnderwearTowel/WashclothBlanketFace MaskWet Wipes
Additional Needs

Shower AccessLaundry AssistanceMobile Hygiene ServicesOther
Preferred Pick-up or Service Location

Outreach EncounterDrop-in CenterMobile UnitShelterOther
Should be Empty:

Required Income Verification Documents