Needs Assistance Form

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Dear Parent/Guardian,
The Coventry Oak Family Resource Center is here to assist you! If you are in need of assistance with clothing for school, food assistance, holiday assistance or other, please complete this form by checking which area(s) would be most helpful to you. Completing this form does NOT guarantee services for any of the areas listed below, nor does it sign you up for specific programs. If given the opportunity to sign up for any of the below programs, you will receive a permission form for each of the individual assistance programs. If you decide not to complete the form but need help in the future as financial situations do change, contact Mrs. Runyon anytime at 381-3196. Please complete this form by September 4th.

Email *

Parent/Guardian First and Last Name *

Coventry Oak Student(s) First and Last Name (Please list each COE student here) *

Does your family need "Blessings in a Bag"? (A weekly snack/food bag would be provided to your COE student(s). *

Yes

Do you need help providing school supplies for your COE student? *

Yes

Maybe (When we return to in-person)

Do you need help with school clothing (dress code items) for school? *

Yes

If you answered "Yes" to needing help with clothing, please list Pant, Shirt and Shoe sizes below...If you answered "No", please skip to next question.

Will you need holiday assistance? (Checking "Yes" does not automatically sign you up for Thanksgiving or Holiday gift assistance help. You will receive an additional sign up for each specific assistance programs.) *

Yes

Thanksgiving Basket (Through God's Pantry)

Holiday gift assistance

List any additional needs you may need help with..... *

Yes

Sometimes or Maybe

Clothing (general clothing needs, not just school clothing)

Food (food basket referrals)

Utility/Rent Resources

Hygiene/cleaning products

Dental/Health Services

Mental Health Resources

If you would like to leave any additional information about needs you have or additional resources you need help with not listed above, please leave that information here, or contact Mrs. Runyon at 859-381-3196.

I understand that by signing this form, I am not guaranteed or automatically signed up for the above programs. I will receive individual permission forms for any assistance program I am eligible for.

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