Welcome! As our new neighbor, we need some information to be able to help you. We will try to assist you in a timely manner but be advised that we have a long list of newly arrived households asking for help. We do not receive funding from government and all helpers are volunteers.

By submitting this form you are consenting to IROC sharing your information with our volunteers and partner organizations who will help us to best serve your needs. 

Al enviar este formulario, usted acepta que IROC comparta su información con nuestros voluntarios y organizaciones asociadas que nos ayudarán a satisfacer mejor sus necesidades.

Надсилаючи цю форму, ви погоджуєтеся, щоб IROC ділився вашою інформацією з нашими волонтерами та партнерськими організаціями, які допоможуть нам якнайкраще задовольнити ваші потреби

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By submitting this form you are consenting to IROC sharing your information with our volunteers and partner organizations who will help us to best serve your needs.
At this time, we are only able to serve families in the locations listed below. Please select your location 
 *
List any other organizations you have already contacted for assistance (even if they have not replied)
What is your country of origin?
1. First and Last name *
2. Email *
3. Phone number *
Alternate Phone number
Street address *
Apartment number
City
State *
ZIP Code
Who is your resettlement agency? *
When did you arrive in the  U.S.A. ? *
What is your current immigration status ? *
What language(s) does your family speak?
Clear selection
How many adult live in your household  *
How many children live in your household  *
How many children in your household are less than 2 years old *
List the name,  age and boy/girl for people in your household
Are your children enrolled in school
Clear selection
Have you received the following items *
Yes
No
Not Applicable
Social Security Number (SSN)
SNAP (food stamps)
EAD card (work permit)
What work experience do you have?
Are you currently employed? 
Clear selection
How can we help your family? Please only list the MOST URGENT items that you need. PLEASE NOTE THAT WE DO NOT PROVIDE FURNITURE.  We can help with smaller household items. (if you are requesting  clothes or shoes please indicate the size).
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