Elevate BC Request for Assistance

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Hello,

This form is intended to help those in our South Florida community who are in need of financial support due to the COVID-19 pandemic. Thank you so much for reaching out to ask for help. Countless Americans have found themselves with greatly diminished income due to COVID-19, so if you work in an affected industry, or have just found yourself with unexpected struggles, please use this form to specify how we can help you meet your needs. You are not alone, and there are people in your community waiting to help you!

We will work hard to partner you with a family or individual who can help ease your financial burden. If you have more than one expense you may need help with, that is fine, so please specify when you reach that section of the form. PLEASE NOTE THAT THE AVERAGE AMOUNT OF TOTAL ASSISTANCE IS ABOUT $150-200.

THIS IS A MANUAL PROCESS, SO YOU MAY NOT BE MATCHED AND HEAR BACK FROM US IMMEDIATELY! Please be patient and know that your request is being heard, and that we are looking for the best possible outcome for you. ***DUE TO RECEIVING AN OVERWHELMING NUMBER OF REQUESTS FOR ASSISTANCE, WE CANNOT SPECIFY A TIME FRAME FOR A RESPONSE RIGHT NOW.***

The personal information you share on this form is completely confidential and will not be shared with anyone until you are matched. It is helpful if you give us some details about your current situation.

***AT THIS TIME, WE ARE REQUESTING THAT ONLY ONE MEMBER OF A HOUSEHOLD APPLY FOR ASSISTANCE. THANK YOU SO MUCH!***

You can always reach out to us with any questions, concerns, or stories you may have about your match at elevatebcinfo@gmail.com!

First Name *

Last Name *

Email Address *

Phone Number *

Current City and State *

Current Zip Code *

Address (please still include city, state, and zip-code) *

Current Work Activity (if more than one current place of employment, please state.) *

Number of Adults in Household *

Number of Children in Household *

Please briefly summarize the impact of the pandemic on your situation. (approx. 150 words or less) *

Please select the category that the assistance you are requesting falls under. (The average amount of assistance is about $200) *

Assistance with food (grocery bills, etc.)

Assistance with utilities (electricity, water, phone, etc.)

Assistance with pharmacy bills

Assistance with child-related expenses (childcare, school supplies, etc.)

Other:

Required

Please tell us the dollar amount you are requesting and what it will be used for. (ex. Fill prescription for heart medication $150) Being specific will help us with your match! *

Are there any other factors of your situation that you think are important to share? (For example, single parent, timing of need, etc.)

How did you hear about Elevate BC?

If any of your children are between the ages of 3-6, we are also able to provide you with a free set of learn-to-read books. If you would like to receive this set, please check yes.

Yes

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