Village Support Form
YAASPA in partnership with other community organizations are working to provide support for students and folks who are temporary/hourly workers.

We want to support our fellow students and families throughout this public health shift.

NOTE: Documentation status does not matter and no documentation is required to complete this form and no documentation is required to receive support.

NOTE: You can complete this form for someone else as well if they are not comfortable completing the form themselves. If you are completing this for someone else, please note that in the comments at the end of the survey. We will still work with you to provide the resources through you to support your friend(s) or family member(s).

Please contact info@yaaspa.net for questions
First Name *
Last Name
Email address *
Phone Number *
Race
Current Education Status (if you are a student completing the form or completing it for another student) *
If in high school school, name of high school?
Number of People in Your Household
Are you a primary caregiver in your household (examples: I care for family financial, I care for siblings, I care for an family member who is ill etc)
Clear selection
Current or last place of employment?
Are you currently an hourly/temporary employee or were you one within the past month? *
Would you like more resources and information on any of the following for you and your household? *
Required
Referred by (how did you find out about this form)
Please provide any additional information about your current status that you feel is important
NOTE: We will get back to you within 48 hours. All information shared will remain confidential and only used to best support you and your family. We are committed to finding ways to support the financial, emotional, mental, and social well-being of youth and families.
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