FARC Assistance Request Form

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Please fill out the form below to receive immediate family assistance. This form is only intended for fire or natural disaster families in New Jersey within a 10 mile radius of HQ.

Email *

Phone Number (Número de teléfono) *

Best way to contact you (La mejor manera de contactar con usted): *

Phone Call

Required

Please select all that apply (Por favor, seleccione todo lo que corresponda): *

Fire Victim (Víctima del fuego)

Flood Victim (Víctima de la inundación)

Homeless (Sin techo)

Catastrophic Illness (Enfermedad catastrófica)

Unemployed (Desempleado)

Veteran (Veterano)

Senior Citizen (Tercera edad)

Individual in Financial Crisis (Individuo en crisis financiera)

Family in Financial Crisis (Familia en crisis financiera)

Other:

Required

Date of Fire (Fecha del incendio)

YYYY

Which organization / agency referred you? (¿Qué organización/agencia le ha remitido?) *

Name of the person from the organization / agency who referred you? (¿Nombre de la persona de la organización/agencia que le remitió?) *

Case Number (Número de caso)

Organization / Agency Phone Number (Organización / Agencia Número de teléfono) *

Organization / Agency Email Address (Organización / Agencia Dirección de correo electrónico)

Full Name (Nombre completo) *

Current Home Address (Dirección actual de la casa) *

City (Ciudad) *

State / Province (Estado / Provincia) *

Zip / Postal Code (Código postal) *

Which of the following best represents your racial or ethnic heritage? Choose all that apply. *

American Indian or Alaska Native (A person having origins in any of the original peoples of North and South American, including Central America).

Asian (A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.)

Black or African American (A person having origins in any of the black racial groups of Africa.)

Hispanic/Latino (A person of Cuban, Mexican, Puerto Rican, Cuban, South or Central American, or other Spanish culture or origin, regardless of race.)

Native Hawaiian or Other Pacific Islander (A person having origins in any of the original people of Hawaii, Guam, Samoa or other Pacific Islands.)

White (A person having origins in any of the original peoples of Europe, the Middle East or North Africa.)

Other:

Required

How many people live in your household? (¿Cuántas personas viven en su hogar?) *

How many household members are children? (¿Cuántos miembros del hogar son niños?) *

How many household members are adults? (¿Cuántos miembros del hogar son adultos?) *

Number of children under 5 years old (Número de niños menores de 5 años) *

Number of children 5 - 9 years old (Número de niños de 5 a 9 años) *

Number of children 10 - 14 years old (Número de niños de 10 a 14 años) *

Number of children 15 - 18 years old (Número de niños de 15 a 18 años) *

Number of adults 20 - 54 years old (Número de adultos de 20 a 54 años) *

Number of adults 55 - 74 years old (Número de adultos de 55 a 74 años) *

Number of adults 75+ (Número de adultos mayores de 75 años) *

How did you hear about us? (¿Cómo nos conoció?) *

Recommended by friend or colleague

Search Engine (Google / Yahoo / Bing / other)

Social Media

Blog or publication

Referral Agency

School Social Worker

Early Intervention Social Worker

School Guidance Counselor

Red Cross

Other:

Additional Comments

(i.e, Name of hotel you stayed at, date checked out of hotel, next place of residence)

Send me a copy of my responses.

Submit

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