FARC Assistance Request Form for Fathers

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This form is only intended for fire or natural disaster families in New Jersey within a 10 mile radius of HQ.

Email *

Full Name (Nombre completo) *

Are you a casualty of fire or a natural disaster? *

YES - FIRE

YES - NATURAL DISASTER

Other:

Required

Are You a Father? *

YES

Required

Marital Staus *

Married

Never Married

Divorced

Widowed

Single / Unmarried

Domestic partnership

Other:

Required

Age and gender of child(ren) *

Do You have custodial rights or not? *

YES

Required

Are You currently employed? *

YES

Required

How many days a week do you work? How many hours?

If You are not currently working, when was your last date of employment?

YYYY

Current Home Address (Dirección actual de la casa) *

City (Ciudad) *

State / Province (Estado / Provincia) *

Zip / Postal Code (Código postal) *

Phone Number (Número de teléfono) *

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

Phone Call

Required

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

Please select the items you need: *

Food Assistance

Furniture

Clothing

Footwear

Other:

Required

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

What are your biggest challenges? Finances? Food? Shelter? Child care? Please let us know.

Send me a copy of my responses.

Submit

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