Freedom Care Finder
Email *
Name *
Cell Phone (we will text you, standard messaging rates will apply) *
Do you attend Freedom Church? *
Category *
Your Area (or the Area of the Person in Need) *
It is our intent to help Los Alamos County residents only. However, if you live outside of Los Alamos County please enter your information and we can do our best to work with organizations in your area to help assist with the need(s).
Financial Assistance *
NEEDS: FOOD
Check all that apply
NEEDS: HYGIENE PRODUCTS
Check all that apply
NEEDS: RELATIONAL
Check all that apply
NEED: PRAYER
NEED: FINANCIAL
We want to help. Yet, we may not be able to cover all financial assistance that you you. At the same time we'll work with you to try and provide financial assistance of some kind.
NEEDS: TECH
Check all that apply
OTHER (For any items not listed above please state them here, there is no guarantee that we can supply this need)
CONSENT *
We realize no activity is without the possibility of unforeseen hazards which could result in injury to an individual. You are aware of your responsibilities of the importance of conduct which will ensure safety. By signing this form, you agree to assume the risks and hazards which are inherent in this kind of activity. You also agree to absolve and hold harmless the sponsoring organizations and their representatives for damage, loss or injury. You also agree to your personal information being shared with the person who will meet my need.
Required
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google.