Request edit access
CAPC Concrete Support (Antioch)
The Child Abuse Prevention Council (CAPC)'s Concrete support is available once per family to families in need. Special needs items may include (but are not limited to): transportation, clothing supplies, school and work uniforms, diapers, strollers, safe cribs, medical supplies, birth certificates, eyeglasses, weighted blankets, prescriptions, tablets for school, and hygiene products.

To be eligible for special needs items, families must have at least one child between the ages of 0-18 living with them. Please note that funding is available once per family and that this is not designed to be emergency assistance - items may take time to prepare for pick up.

To request an item, please complete the following google form and submit it. The form must be completed by a service provider (not a family member). For efficiency please email Adempsey@capc-coco.org with any relevant material to support referral submitted (e.g. Utility bills, information on how to complete third party payments, ect.) CAPC will arrange for the service provider to pick up the items from our Concord location at 2120 Diamond Blvd., #120, Concord, CA 94520. For questions or for more information, please email Ana Dempsey at Adempsey@capc-coco.org

For non-Antioch referrals please submit referral on our countywide google form.
(Funding is currently paused, will be reviewed when possible)
Sign in to Google to save your progress. Learn more
Service Provider Name *
Requesting Agency *
Service Provider Email *
Service Provider Phone
Total Number of children in the Household (under the age of 18) *
Parent/Guardian's Name *
Family's Address (Antioch Families) Please include full address city and zipcode *
Confirmed City of Antioch residents *
Required
Primary Language Spoken in the Home *
Ethnicity *
Item Needed (If requesting a utility bill, please email a copy of the bill to sstanwood@capc-coco.org) *
Statement of Family Needs/Situation (Please elaborate on how this aid can support the needs and elaborate on how family will meet this need in the future) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of CAPC COCO.

Does this form look suspicious? Report