POD Start Up and Service Gap Request Form

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Please fill out the following form and someone will get back to you as soon as possible.

Please note that: 1) Applying for help in no way guarantees that we can help at any given time. Our ability to make these resources available is entirely dependent on donations. 2) This is not cash funding; we only offer credit for and/or harm reduction supplies.

Email *

Organization/Collective/Project Name *

I/ we are a: *

Emerging/grassroots group providing syringe access or harm reduction services.

Emerging/grassroots group who wants to provide syringe access or harm reduction services.

An existing fiscally sponsored currently providing syringe access or harm reduction services.

An existing Independent 501c(3) organization currently providing harm reduction services.

Other:

We are seeking: *

Start-up support for new services.

Support during a short term service provision gap.

Other:

Have you sought support from POD in the last 6 months? *

Yes

Other:

If you get help from us are you willing to help promote the fund when possible in order to "pay it forward" so supplies can be available to other organizations? *

Yes

Other:

Does your organization follow the Principles of Harm Reduction? *

Yes

Other:

Please tell us a little about your situation and why you are seeking support at this time. Please include any information about other sources of funding/supplies you have tried to access or are in the process of accessing including grants, private donations and/or government support. *

If you are asking for gap supplies please tell us what you need and how much would be ideal. PLEASE NOTE: This is no guarantee that you will get what you ask for, we are limited by available funding. *

If you are seeking start up supplies please let us know approximately how many folks you serve on a weekly basis and what supplies your community prefers. PLEASE NOTE:This is no guarantee that you will get what you ask for, we are limited by available funding. *

Contact Person *

Shipping Address *

Phone Number *

Website (if applicable) *

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