Assistance Request Form
Please answer the following questions to the best of your ability. All requests will be reviewed and you will be contacted for additional information if needed. We are doing our best to help as many as we can. Thanks for your understanding, God bless you.
First and last name
What kind of assistance do you need?
Financial (Payment/Bills of all sort)
Equipment (wheelchair, walker, crutches, shower chair etc)
Please elaborate on the assistance you need.
Do you have any proof / form / photos / invoice supporting the fact that you need the requested assistance?
It's OK if you don't. Please answer truthfully.
Are you disabled?
Please answer truthfully. There is no right or wrong answer. We plan to help everyone in need.
If you answered yes above, briefly explain what your disability is.
If you answered no, simply put NA or skip this question.
Phone number or Instagram handle
A copy of your responses will be emailed to the address you provided.
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This form was created inside of thediylady.com.