Family Assistance Intake Form

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Does your family need assistance in order to meet their needs? If so, please complete this form. During the 2020-2021 school year, Coventry Social Workers will add an anonymous texting service called “Remind 101”. This will help families receive private, quick, and simple up to date information (directions for signing up will be sent home once this form is completed). Please note that resources may be very limited, and completing this form is NOT a guarantee of assistance.

Parent Name(s) *

Student Name(s) *

Address *

Mobile Phone Number (to receive text message updates)

Email *

Check all needs that apply to your family: *

Clothing/Footwear (You will receive another form if you check this box)

Food (Information about access to School/Community partners and programs)

Holiday Assistance (You will receive another form if you check this box)

Covid-19 Safety Supplies (Masks, thermometers, etc.)

Other:

Required

Additional Information

When/if the School Social Workers are made aware of community events or resources, as a member of our assistance program you will receive information as the Social Workers see fit.

Parent Signature: *

Date: *

YYYY

Submit

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