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.
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.
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.

Mass 2-1-1SNAP (food assistance)TAFDC (cash support for families with children)HomeBASE / Emergency AssistanceRAFT (Residential Assistance for Families in Transition)WIC (Women, Infants, & Children)Local Food Pantries & Community Action AgenciesSalvation Army (Local CorpsCradles to CrayonsSt. Francis House (BostonCommunity Action Agencies (Local CAAs)Other
Essential Clothing Items Needed (Please select all that apply)

Adult clothingChildren's ClothingShoesCoatsJacketsSocks & Underwear
Kitchen Essential Needed (Please select all that apply)

Pots & pansDishes/Plates/bowlsCups/GlasswareSilverwareStorage ContainersCooking Untensis
Household Essential Needed (Please select all that apply)

Bedding (sheets, pillows, blankets)TowelsWashclothsCleaning SuppliesTrash Bags
Personal Care & Hygiene Items Needed (Please select all that apply)

Toiletries (soap, shampoo, toothpaste, etc.)Diapers/WipesFeminine Hygiene Products
Children & Family Needs (Please select all that apply)

Baby itemsSchool SuppliesToys / comfort items
What Are Your Top 3 Most Crucial Essentials?
What programs are you currently in, if any?

SNAPWICTAFDC (cash support for families with children)Other
Are you ok with gently used items as a donation to help you, while you are trying to get on your feet?

YesNo
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?
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