Basic Needs Fulfillment Program

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The Fayette County Family Resource Network (FRN) was awarded a responsive funding grant in January 2024. The purpose of this grant is to provide basic needs items to residents within Fayette County. Basic needs can include, but not limited to: beds, dressers, children and adult clothing, and household items.

This request form needs to be completed by a direct service provider, not the individual needing assistance. Verifying that an individual is receiving additional services through community organizations is vital to ensuring these funds are being used appropriately.

These grant funds are available from January 1, 2024 through December 31, 2024 (or until funds run out).

If you have any questions about this request form, or the funding received, reach out to Diane Callison, Director of the Fayette County FRN at 304-575-1428 or fayettefrn@gmail.com

The Basic Needs Fulfillment Program has been made possible in part by a grant from The Greater Kanawha Valley Foundation.

Referring Organization *

Referrer Name *

Referrer Email Address *

Referrer Phone Number *

Individual Information

Please provide information on the individual who is in need of assistance. Data will be collected and presented to the grant funders. No personal identifiable information will be used in the data report

Individual Name *

Individual Address (Street, City, State, Zip) *

Individual Phone Number *

Individual Gender *

Male

Female

Other:

Individual Age *

19-24

25-40

41-64

65+

Individual Race *

African American

Asian/Pacific Islander

Caucasian

Hispanic

Multi-Ethnicity

Native American

Other:

Number of people in the household *

Are there children within the home? *

Yes

If this individual has children, please list their age and genders.

Is this individual currently employed? *

Yes

Other:

Please indicate income level of the individual *

Low Income (less than $22,000)

Middle Income (between $22,00 and $69,000)

Upper Income (Over $70,000)

Other:

What resources have you reached out to in order to fill this need? Check all that apply. *

DHHR

FRN Email List

Medical Providers

Community Organization

School System

Other:

Required

Please list all the items this individual needs assistance with. Be as detailed as possible including bed sizes, clothing sizes, etc. *

Please provide any time restrictions or deadlines that the individual has on receiving these items. If none, put N/A *

Any additional comments or information we should be made aware of. *

Electronic Signature

Type your full name in the space available signifying that you agree to the statement below.

I hereby certify the facts set forth in the above application are true and complete to the best of my knowledge. *

Submit

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