Neighbor Connect+ – Request Help Form
Please fill in the form below
Full Name
*
First Name
Last Name
Address/City/State/Zip (We use this information to coordinate deliveries)
*
Street Address
Street Address Line 2
City
State / Province
Zip Code
Phone Number
E-mail
*
example@example.com
How should we contact you?
*
Phone Number
Email
Other
If you prefer to be contacted by phone please provide the days/times are you available for follow-up?
How Can We Help?
What kind of help do you need?
*
Food
Shelter
Clothing
Job Help
Holiday Assistance
Other
To provide you with more personalized assistance, please describe your situation or needs in detail.
Tell Us a Little More
Household Size
Please Select
1
2
3
4
5+
Are there any children in your household?
Yes
No
Any Specific Needs or Allergies?
(e.g., "infant formula," "diabetic-friendly," "size 10 shoes")
Is this a one-time need or ongoing support?
Please Select
One -Time
Ongoing
Do you have transportation?
*
Please Select
Yes
No
If you don't have transportation, are you comfortable with receiving deliveries?
*
Yes
No
Are you a US citizen?
*
Yes
No
Are you over the age of 18?
*
Yes
No
How Did You Hear About Us?
*
Please Select
Word of Mouth
Social Media
Community Partner
Online Search
Website
I understand that Neighbor Connect does not provide financial assistance and that this information will only be used to locate and if needed transportation to community resources.
*
Yes
Please verify that you are human
*
SUBMIT
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