LIFT Mercy Fund Application
COVID-19 Related Emergency Assistance Application
Name *
Address *
Phone number *
How has your situation been impacted by the COVID-19 pandemic, either directly or indirectly? *
If "other," please explain
Assistance Requested *
Please explain in further detail the assistance you are requesting, so we can better understand your needs. *
How soon do you need these services? *
What additional assistance, if any, do you need? Please be as specific as possible including the frequency and urgency.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy