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Welcome! As our new neighbor, we need some information to be able to help you. We will try to assist you in a timely manner but be advised that we have a long list of newly arrived households asking for help. We do not receive funding from government and all helpers are volunteers.

By submitting this form you are consenting to IROC sharing your information with our volunteers and partner organizations who will help us to best serve your needs. 

Al enviar este formulario, usted acepta que IROC comparta su información con nuestros voluntarios y organizaciones asociadas que nos ayudarán a satisfacer mejor sus necesidades.

Надсилаючи цю форму, ви погоджуєтеся, щоб IROC ділився вашою інформацією з нашими волонтерами та партнерськими організаціями, які допоможуть нам якнайкраще задовольнити ваші потреби

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By submitting this form you are consenting to IROC sharing your information with our volunteers and partner organizations who will help us to best serve your needs.
At this time, we are only able to serve families in the locations listed below. Please select your location:
[NOTE: except for emergencies, people in Maryland and Virginia outside of the listed locations can receive information from IROC and join our WhatsApp groups, but are not eligible for material assistance such as new items.] *
List any other organizations you have already contacted for assistance (even if they have not replied).
What is your country of origin? *
First and Last name *
Email *
Phone number *
Alternate phone number (optional)
Street address *
Apartment number
City *
State *
ZIP Code
Who is your resettlement agency? *
Is your resettlement agency virtual? *
Please put your caseworker's name here. If you do not have a caseworker, you can write "none". *
Please put your caseworker's phone number here. If you do not have a caseworker, you can write "none". *
When did you arrive in the U.S.A.? *
MM
/
DD
/
YYYY
What is your current immigration status ? *
What language(s) does your family speak?
Clear selection
How many adults live in your household? *
How many children live in your household? *
How many children in your household are less than 2 years old? *
List the name, age, and gender (boy/girl) for ALL people in your household, including yourself.
Are your children enrolled in school?
Clear selection
Have you received the following items? *
Yes
No
Not Applicable
Social Security Number (SSN)
SNAP (food stamps)
EAD card (work permit)
What work experience do you have?
Are you, or is someone in your household, currently employed?  *
If no one in your household currently has a job, explain in what ways you are trying to find employment. An example of a  CV/resume formatted for US job market is provided here.
If no one in your household currently has a job, are you (or someone else in your home) willing to take an entry level/manual job ($15/hour) which may require commuting by bus/train for an hour each day, while you look for a better opportunity? 
 *
How can we help your family? Please only list the MOST URGENT items that you need. PLEASE NOTE THAT WE DO NOT PROVIDE FURNITURE OR RENT ASSISTANCE. We can help with smaller household items. (If you are requesting clothes or shoes please indicate the size).
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