Mount Carmel HELPS, Inc. — Emergency Assistance
Please complete the following to request emergency assistance for your household.
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Section 1: Family Information
Head of Household Name *
Date of Birth   *
MM
/
DD
/
YYYY
 Phone Number   *
Email Address *
Home Address *
County of Residence   *
Preferred Contact Method *
Required
Section 2: Assistance Request-at this time we do not have anymore salt, coats, socks, or gloves
Please describe emergency assistance need *
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