Railyard Herbal Justice Fund Request Form
Who is eligible?

​-BIPOC (black, indigenous, people of color) folks and senior citizens regardless of income

-Those who may self-identify as meeting one of the following criteria:
Living on fixed government income (SSDI, SSI, Social Security, unemployment)
Receiving public assistance
Unemployed
Houseless
Paying 50% or more of income for housing
Are struggling to support children or other dependents
Have significant debt
Have medical expenses not covered by insurance

If you meet eligibility, please answer the following questions:
Name
Your answer
Date
MM
/
DD
/
YYYY
Phone
Your answer
Email
Your answer
Mailing Address
Your answer
Which services would you like to access? (sliding scale costs listed for members of the herbal justice program)
How much are you able to pay out of pocket per month?
Your answer
How did you hear about this program?
Your answer
Submit
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