Family interest form

Family Interest Form

Support, connection, and care—designed with your family in mind.
We’re building programs to support families navigating disability, caregiving, and educational gaps—with flexibility, compassion, and joy. If you’d like to be notified when services open, we’d love to hear from you.
Our programs are designed especially for rural, homeschool, minority, first responder, and military families—and always with heart.
Family Information
Parent/Caregiver's name*

First NameLast Name
Name of the family member you're reaching out for*

First NameLast Name
Age *

MonthDayYear
Date
What diagnosis or condition does your loved one have? (Optional)
This helps us shape programs that truly serve your family. All information is kept private and used only to guide support.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Are you a:*
What services are you interested in?*

ASL classesBraille classesTherapy ReimbursementRespite CareDevice Support (AAC/AT/Medical)Support GroupsEnrichment Vouchers (Swimming, Dance, Karate, Music, etc)Advocacy or IEP SupportOutreach EventsCaregiver support (vouchers for self-care)
Tell us a little bit about your family's needs *
This helps us shape programs to truly suit you
How did you hear about us? *
Acknowledgment*

I understand that Hearts and Hands Foundation is applying for 501(c)(3) status and services are not yet available. I’m expressing interest only and will be notified when programs launch.
Signature acknowledgement
By signing below, you acknowledge that you are joining the Hearts and Hands Foundation interest list and consent to being contacted when programs officially launch. This does not enroll you in services or guarantee availability, but helps us understand your needs and keep you informed.*

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Family Interest Form

Family Information

Signature acknowledgement