Hardrock Chapter Community Assessment
This is only an Assessment
Date of Birth *
Name *
Are you filling this form out on behalf of someone else? *
Are you enrolled with the Navajo Nation (Have a CIB dated before March 1, 2020) *
Are you a registered voter with Hardrock Chapter ( You are not required to be registered with the chapter but apart or from the Hardrock community) *
Physical Address *
Mailing Address *
Phone Number (Please leave number, if additional information is requested on your behalf) *
Email Address:
Do you have water connected to your home? *
Do you have electric to your home? *
How were you affected by the current COVID 19 pandemic. Please explain. *
The CARES Act Funding allows assistance, with the following. In which area do you feel you need the most assistance during this pandemic. You can select multiple answers.
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