Needs Assessment Form | His Hands Family Out

We do not offer rental assistance

Needs Assessment Form
(For Single
Parents/
Guardians Only)

Please review the Guidelines for Assistance before submitting this form.

Please allow 24-48 hours after submitting your application for us to review it. Feel free to follow up after that time if you have not heard back.

First Name

Last Name

Street Address

City

Region/State/Province

Postal / Zip code

Phone

Marital / Parental Status - Please check one..

Please click all that apply and add additional information, if needed, in COMMENTS section below. You must be registered with us to receive any assistance.

Food-Gift cards are from Walmart and restricted (no tobacco, alcohol or firearms can be purchased). Eligibility - quarterly.

Utility Assistance - (when funds are available). Eligibility - quarterly.

Birthday Cake Kit - (see Guidelines Page for description). Eligibility - once per year per child.

School Supplies Bank. Eligibility-throughout the school year (if supplies are available).

Other - Please explain in COMMENTS section below

COMMENTS Section - please add additional information according to the needs you checked above. If this section doesn't apply, please type N/A

I accept terms & conditions

Thanks for submitting!

*We do not offer rental assistance* Needs Assessment Form (For Single Parents/ Guardians Only)

Marital / Parental Status - Please check one..

COMMENTS Section - please add additional information according to the needs you checked above. If this section doesn't apply, please type N/A

Children (first name & age). Enter N/A if you are a Senior Citizen with no children living at home.

We do not offer rental assistance

Needs Assessment Form
(For Single
Parents/
Guardians Only)