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
* Required
First Name
*
Your answer
Last Name
Your answer
Email address
*
Your answer
Phone Number
*
Your answer
Race
Your answer
Current Education Status (if you are a student completing the form or completing it for another student)
*
High school
Trade/Vocational School (Career Tech Education)
College
Graduate School
n/a
Other:
If in high school school, name of high school?
Your answer
Number of People in Your Household
1-3
4-6
7-9
10 and over
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)
Yes
No
Sometimes
Clear selection
Current or last place of employment?
Your answer
Are you currently an hourly/temporary employee or were you one within the past month?
*
Yes
No
Other:
Would you like more resources and information on any of the following for you and your household?
*
Housing
Electricity/Utilities
Heat/AC
Rent/Mortgage
Food/household supplies (including toiletries, feminine products, hygiene products etc)
Internet/Wifi
Educational resources
Health Care
Mental Health
Child Care
Technology (tablet, computer, chrome book)
Transportation
Other:
Required
Referred by (how did you find out about this form)
Your answer
Please provide any additional information about your current status that you feel is important
Your answer
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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