Hygiene Assistance Form
For individuals seeking hygiene support services or supplies
Full Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Are you currently experiencing homelessness?
*
Yes
No
Current Living Situation (check one):
*
Unsheltered(street/tent/car)
Emergency Shelter
Transitional Housing
Doubled Up with Friends/Family
Other
Source of Income (check all that apply):
*
Employment
Unemployment
Disability
Social Security
Food Stamps
Child Support
No Income
Required Income Verification Documents
(Please attach or provide one of the following)
Last 2 Pay Stubs
Benefit Award Letter
Bank Statement
Unemployment Statement
Food Stamp Award Letter
Written Statement of No Income
File Upload
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Toiletries
Toothbrush& Toothpaste
Soap/BodyWash
Deodorant
Shampoo/Conditioner
Lotion
Feminine Hygiene Products
Razors/Shaving Cream
Comb/Brush
Nail Clippers
Clothing& Supplies:
Socks
Underwear
Towel/Washcloth
Blanket
Face Mask
Wet Wipes
Additional Needs
Shower Access
Laundry Assistance
Mobile Hygiene Services
Other
Preferred Pick-up or Service Location
Outreach Encounter
Drop-in Center
Mobile Unit
Shelter
Other
Submit
Should be Empty: