Hurricane Harvey Assistance Request Form
Assistance offered by the National Federation of the Blind of Texas is intended to provide support for blind and low vision Texans, and other members of their households, affected by Hurricane Harvey. Please complete this brief form to assist us with getting the proper assistance to you. We will notify you regarding what assistance we can make available to you within 24 hours of receiving your request. Once we have notified you regarding your assistance, we will make every effort to provide any promised assistance within a week of the notification.

Please answer all questions as thoroughly as possible so that we can provide the help you need.

Name *
Your answer
Date of Birth *
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DD
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Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Telephone *
Please provide us with the best number to reach you in case we have questions.
Your answer
Email Address
Your answer
Assistance Requested *
We may purchase some products. However, assistance is likely to come in the form of a check or gift cards(s). We also have access to some funds to assist with transportation needs. We cannot guarantee that our assistance will meet all your immediate needs, but we will make every effort to provide meaningful help.
Required
Number of family members *
Your answer
Names and ages of other family members *
Your answer
Other information that might help us provide the best assistance possible.
Your answer
I certify that I am legally blind and that I was impacted by Hurricane Harvey. I further certify that any funds received will be used for storm recovery. *
Required
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