Grocery Assistance Application Form
During this extremely difficult time, HAYLEN Group is aware of the financial struggles small business owners and their employees are currently facing due to COVID and families around the BAY area due to the fire. We are committed to helping members of the Silicon Valley community by identifying those who face immediate financial need. In doing so, we are asking that you complete the following application to assist us in identifying  our local families in need who would each benefit from a $250 grocery gift card from the grocer of their choice or doordash.                                                            

We will review ALL questionnaires received.

Please keep an eye on your inboxes and junk mail. A representative from HAYLEN Group will send a follow up email to those we have selected, in order to gather further information before making our final selections.  We ask that you be truthful and forthright about your financial needs. Please do not take advantage of this program. If this assistance does not apply to you but you know a small business owner, or someone who lost their job or their home whom it may benefit, please forward them the this application.

If you'd like to be a sponsor as well, please sign up here:

For any other questions about this offer, please email (Lic. 01700495)
Email *
Please provide your First and Last Name
Home Address
Phone number for us to contact you regarding your application.
(Optional) What was your business or occupation prior to being laid off or closed down?
Do you have any other income during this time? If yes, please explain.  
Clear selection
How many household members do you have?
Clear selection
(Optional) What is your biggest struggle due to the Coronavirus Pandemic/CZU, LNU, & SCU Fire? Please share your story.
Would you like to be interviewed (either on or off camera) to discuss your current situation and allow us to share your story? Our goal is to share small businesses or families stories to the world and let everyone hears about them.  
Clear selection
Fighting Depression and Keeping Family Strong with Shelley
Keeping Her Children Happy with Melissa
Clear form
Never submit passwords through Google Forms.
This form was created inside of Side, Inc.