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Assistance Request Form
Please answer the following questions to the best of your ability. All requests will be reviewed and you will be contacted for additional information if needed. We are doing our best to help as many as we can. Thanks for your understanding, God bless you.
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* Indicates required question
Email
*
Your email
Name
*
First and last name
Your answer
What kind of assistance do you need?
*
Medical
Financial (Payment/Bills of all sort)
Counselling/Advice/Encouragement
Equipment (wheelchair, walker, crutches, shower chair etc)
Other:
Required
Please elaborate on the assistance you need.
*
Your answer
Do you have any proof / form / photos / invoice supporting the fact that you need the requested assistance?
It's OK if you don't. Please answer truthfully.
Yes
No
Clear selection
Are you disabled?
*
Please answer truthfully. There is no right or wrong answer. We plan to help everyone in need.
Yes
No
If you answered yes above, briefly explain what your disability is.
If you answered no, simply put NA or skip this question.
Your answer
Phone number or Instagram handle
Your answer
A copy of your responses will be emailed to the address you provided.
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