We Impact ATX Assistance Request
We Impact ATX is a combined effort between several community churches and leaders who have committed to help people in need in Austin during the COVID-19 crisis and beyond. Our goal is to serve the community by providing FREE food and essentials to those in need.

We will deliver the groceries to disabled seniors/elderly free of charge. Other families in need will receive a gift card to HEB.

We ask that each person needing assistance fill out this form so we can provide the necessary food items as they are available.

Please answer each question so we can accurately fulfill your order. Please put N/A in each field that does not apply.

After you fill out this order request, we will contact you to go over details and availability before the order is completed. If you would like faster service, you have additional questions, or you need assistance filling out this order request, please contact us at admin@weimpactatx.org or (512) 956-8526.
To ensure we can meet the needs of many, we do limit the amount of times an individual can request assistance.

Thank you for your cooperation!
Email *
First Name *
Last Name *
Address *
City *
Contact Number *
Number of people in household *
Number of people in household above the age of 18 *
First and Last names of people in the household above the age of 18 *
Have you or someone else made a request to We Impact ATX on your behalf before? *
Are you 60 or above? *
Are you disabled, mobility challenged, and unable to drive? *
Are there other items you may need? We will do our best to accomodate.
What item(s) do you need? *
Required
Dietary and Health Restrictions (i.e. food allergies, food intolerance, etc.) *
Please share questions, comments, concerns, or any additional information.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Victorious Living Christian Ministries. Report Abuse