Harper & Paulyne Gerry Student Assistance

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Email address of person filling out this form *

Name of person filling out this form *

Relation to person needing support. *

Phone number of person filling out this form *

First name of family needing support *

Last name of family needing support *

Mailing address of family needing support *

Email of family needing support *

Phone number of family needing support

Names, ages and gender of children in household? *

What type of help does the family need? *

Help with food

Help with shoes

Help with clothing

Help with paying rent

Help with paying utilities

Help with childcare

Help with eyeglasses

Other:

Please describe in detail how the Mary Lyon Foundation can support this family. *

Name of school or schools that children attend? *

Is the family aware that you are contacting the Mary Lyon Foundation for help?

Yes

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