Assistance Request Form
United Way of the Yampa Valley is here to do our best to provide support to families affected by the devastating Wildfires. If you or your loved ones have found yourself without the resources you need, please complete the form, and a representative from United Way will be in touch to help in any way we can. We appreciate your patience while we respond. Please know that we will respond to each request as we are able. Please call the United Way office with Questions: Mo Macchia #970-879-5605 ext. 106
Main Contact Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address (if different)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Alternate Contact Full Name
First Name
Last Name
How You Know Alternate Contact
Alternate Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Alternate Contact Email
example@example.com
County You Reside In
*
Moffat
Rio Blanco
Routt
Do You Rent or Own Your Home?
*
Rent
Own
How many adults 18+ are in the home
*
How many children 5-17 are in the home
*
How many children 0-4 are in the home
*
Do You Have Any Pets That Need Support?
Please List All Vehicles With You
*
What types of support do you need? (e.g. food, clothing, housing, animal support, counseling)
*
Are You Receiving Assistance From Another Organization?
*
Yes
No
If Yes, Please List The Organization(s).
Submit Request
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