Individual Needs Request Form

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Please answer all questions below to the best of your ability.

Which school site are you associated with or near? *

Are you a student, community member, or family member? *

Student

Community Member

Family Member (Parent, sibling, grandparent, significant other, etc)

First and Last Name *

Phone Number *

Email *

Which item(s) would you like to request?

Please select all that apply below:

1. Toiletries:

Soap

Shampoo and conditioner

Toothbrushes and toothpaste

Toilet paper

Paper towels

Feminine hygiene products

Personal hygiene products (e.g., deodorant, razors)

2. Household supplies:

Cleaning products (e.g. disinfectant, clothes)

Laundry supplies (e.g., detergent, fabric softener)

Garbage bags

3. Food and groceries:

Non-perishable food items (e.g., canned goods, vegetables, fruits, soups, rice, pasta)

Bread and bakery items

Dairy products (e.g., milk, cheese, yogurt)

Fresh produce (e.g., fruit, vegetables)

Snacks and beverages

Would you like information on a food assistance program?

Yes

Clear selection

4. Clothing or Family Care Items

Clothing (e.g., shirts, pants, jackets)

Shoes

Diapers

Baby clothes and supplies

Children clothes

5. Financial assistance:

Utility bill payments

Rent or mortgage assistance

Transportation vouchers or assistance

Other:

6. Educational resources:

School supplies (e.g., notebooks, pens, backpacks)

Books and educational materials

Computers or tablets

Other:

7. Medical and healthcare:

Prescription or over the counter medications

First aid supplies

Medical equipment (e.g., crutches, wheelchair)

Other:

8. Other specific needs (eg. large household appliances, childcare services, employment assistance.)

Please specify:

Submit

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