• Your Information
  • Assistance
  • Emergency Contact
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Contact Information

Full Name (include middle initial)

Birthdate

Address

City

State

Zip

Gender

Home Phone

Work Phone

Cell Phone

Accept text messages?

Email

Best time to reach you?

Where did you hear about us?

Marital Status

If Other, please explain:

Is your gross household income at or below: 1 person < $1,316/month, 2 people < $1,784/month, or 3 < $2,184/month

Note: Income level will not exclude you from receiving services through Interfaith. Income level used to determine eligibility for services provided in partnership with our local food pantry.

Is English your primary language?

Have you served in the US Military?

Has your spouse served in the US Military?

If you are a member of an area congregation, please help Interfaith build its community relationships by sharing the name of your church or place of worship:

Ethnicity (optional)

Other:

Living Arrangements

If Other, please explain:

Mobility

Do you have difficulty getting into a van, truck or SUV?

Do you use a portable oxygen cylinder when traveling?

Do you currently hold a valid driver's license?

If no, what is your current means of transportation?

Other:

Have you been convicted of a crime?

Interfaith Caregivers of Washington Co. will conduct a public record check on all applicants and will share the results of this information with a volunteer. Interfaith reserves the right to refuse services to any care receiver.

Assistance Requested

Transportation requests require AT LEAST 10 days' advance notice. Other services require 2-3 weeks to make arrangements.

What are you requesting assistance for?

Other assistance:

Does anyone in your home smoke?

Are there any pets in your home?

If yes, what are they?

Other pets:

Are there any firearms in your home?

Emergency Contact

If living with a spouse or other family member, please provide their information.

Full Name (including middle initial)

Relationship

Address

City/State/Zip

Home Phone

Cell Phone

Additional Emergency Contact

We require an additional contact whose information is different from the care receivers.

Full Name (including middle initial)

Relationship

Address

City/State/Zip

Home Phone

Cell Phone

Acknowledgment

I acknowledge the above information is correct. I also understand that this information may be shared with Interfaith staff and volunteers associated with Interfaith Caregivers of Washington County to provide safe and complete volunteer assistance. This information may also be shared to comply with federal reporting requirements.

Please type your name (Digital Signature)

Date