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Help Request Form

1. Who are you completing this form for? *This question is required.
2. Are you a Neighborhood House employee? *This question is required.
2. Is your client : *This question is required.
2. How may we contact you? *This question is required.
2. How may we contact the client?
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid email address.
4. Which of the following benefits are you receiving? Select all that apply. *This question is required.
6. What do you need help with? Select all that apply.
  *This question is required.
7. Do you need diapering resources?
7. Are you a resident of the following housing authorities?  *This question is required.
7. Are you or someone in your household a community college student? *This question is required.
7. Are there children under age 18 in the household? *This question is required.
7. Are the children in the household students in either the Highline or Tukwila School Districts? *This question is required.
7. Are the children in the household students in Seattle Public Schools?
7. Are you over age 55? *This question is required.
7. Do you have a disability?  *This question is required.
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