Hardship Assistance Request Form

Hardship Assistance Request Form

By completing this form, you are reaching out for support during a difficult time in your life.
Please note this form is specially designed to help those during a hard time in their life
- Those who have all of sudden become ill unexpectedly and under going treatment
- Victim to a mother nature disaster
- Domestic Violence
- Drug Abuse
We understand that unexpected hardships can impact your home and result in the loss of essential items such as clothing, everyday kitchen necessities, and other everyday needs.

Smiles After the Storm is here to offer help and support as you begin to recover. While our resources are limited, we are committed to assisting as many families as possible.

PLEASE MAKE SURE TO FILL OUT THIS ENTIRE FORM AND BE AS DETAILED AS POSSIBLE IN YOUR ANSWERS. IF APPROVED, THE MORE DETAILS WE HAVE THE BETTER WE CAN HELP YOU AND YOUR FAMILY!
Your Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of People in Household
List Children & Ages in Your Household
Check All Other Programs You have Applied For, if any.

Other
Essential Clothing Items Needed (Please select all that apply)
Kitchen Essential Needed (Please select all that apply)
Household Essential Needed (Please select all that apply)
Personal Care & Hygiene Items Needed (Please select all that apply)
Children & Family Needs (Please select all that apply)
What Are Your Top 3 Most Crucial Essentials?
What programs are you currently in, if any?

Other
Are you ok with gently used items as a donation to help you, while you are trying to get on your feet?
What is the best email to send resources to?
example@example.com
Are there any other immediate concerns you have for you, your family or child's wellbeing at this time?
Please Tell Us Your Story
Are There Any Other Details We Should Know?
Applicant Certification & Acknowledgment

By checking the box below and submitting this application, I certify that all information I have provided to Smiles After the Storm, Inc. is true, accurate, and complete to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in my request for assistance being denied or, if assistance has already been approved, withdrawn.I understand that submitting this application does not guarantee approval or assistance. All requests are reviewed based on individual circumstances, available resources, and the guidelines of Smiles After the Storm, Inc.I have read and agree to the above statement and certify that the information provided in this application is true and accurate to the best of my knowledge.
Signature
Donation Inquiry Disclaimer

By submitting this form, you acknowledge that this is a request for information only and does not constitute a commitment or obligation to donate. Submission of this form does not guarantee acceptance, solicitation, or receipt of a donation. All donations are voluntary, subject to availability, and may be declined at the organization’s discretion. Information provided will be used solely for the purpose of responding to your inquiry and will not be shared or sold to third parties.
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Hardship Assistance Request Form

Donation Inquiry Disclaimer