Mutual Aid Intake Form

Administrative Notes

Amount disbursed, date, etc.

Volunteer's Name

First NameLast Name

Volunteer Role

Date

Intake Method

How did you communicate with the requester to gain the information below?

Requester's Name

First NameLast Name

Requester's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Requester's Email

Confirmation Emailexample@example.com

Zip Code

Preferred Language

Total Adults in Household

Total Children in Household

Type of Assistance Requested (select all that apply)

Frequency of Assistance

Amount Requested

The amount disbused will not exceed $500.

Estimated Duration (if ongoing)

Due Date (if applicable)

Tell us the invoice due date, even if it's past due.

Provide a short, factual summary of the person’s situation and needs. Use neutral language and include only verifiable or observed information. Avoid interpretations, assumptions, or opinions.

Vendor / Landlord Name (if applicable)

Only enter the name of a vendor like ComEd, Nicor, or landlord's name.

Vendor Account Number (if applicable)

Only enter account numbers not phone numbers.

Bill Viewed by Volunteer?

Payment Method

We do not do eletronic transfers like Zelle or ApplePay.

Assistance denied from other agencies?

Received assistance from Camino Rising before?

Mutual Aid Volunteer Attestation & Confidentiality Agreement
Camino Rising – Healing Hearts, Restoring Lives

1. Truthfulness & Accuracy of Submission
By signing below, I affirm that:

The information I am submitting in this form is true, accurate, and complete to the best of my knowledge.
The request for assistance reflects a legitimate need as represented to me.
I have not knowingly misrepresented facts, altered documentation, or omitted material information.
I understand that Camino Rising relies on this information when determining whether to disburse funds.
I acknowledge that knowingly providing false or misleading information may result in denial of funding, removal from future participation, and potential legal consequences if fraud is involved.

2. Confidentiality & Non-Distribution of Information
I understand that, through this process, I may have access to sensitive personal information about the applicant, including identifying, financial, or situational details.

I agree that I will:

Not sell, share, disclose, distribute, publish, post, or otherwise transmit applicant information to any individual, organization, business, or government agency unless required by law.
Not use applicant information for personal, political, commercial, or fundraising purposes.
Take reasonable precautions to safeguard documents, communications, and identifying details.
Limit use of applicant information solely to the purpose of completing this request for assistance.
These confidentiality obligations continue after submission of this form.

3. Independent Volunteer Status
I understand that:

My participation in mutual aid activities is independent and not under the day-to-day supervision or control of Camino Rising.
Camino Rising’s involvement is limited to reviewing submitted documentation and determining whether to disburse funds.
I am not authorized to represent myself as an employee, agent, or official spokesperson of Camino Rising.

4. Acknowledgment
By signing below, I acknowledge that I have read, understand, and agree to this Attestation and Confidentiality Agreement.

Volunteer's Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Volunteer's Email Address

example@example.com

Signature of Volunteer or Camino's Representative

Mutual Aid Intake

Section 1: Intake Volunteer Information

Section 2: Requester Information

Section 3: Assistance Requested

Section 4: Brief Situation Summary

Section 5: Payment Information (If Applicable)

Section 6: Prior Assistance

Section 7: Volunteer Attestation