Family Assistance | Safe Harbor

Family Assistance Request

PLEASE NOTE: if applying online, appointment/assistance is NOT complete or guaranteed until you receive a confirmation email from one of our staff members verifying your request. Please allow 24 business hours to receive confirmation.
Information gathered for demographic collection only. Your personal, identifying information will not be shared outside our agency. This information will NOT help or hurt your ability to receive assistance.

First Name

Last Name

Phone

Birthday

Driver's License Number

Street Address

City

State

Postal / Zip code

How did you hear about Safe Harbor? (if referred from another agency, please list your case worker)

Are you currently employeed? (answer yes for part or full time employment)

Yes

Is any OTHER member of your household employeed?

Yes

Are you or any other member of the household currently on unemployment?

Yes

Are you or any member of the household currently receiving disability?

Yes

Number of adults in the household (including yourself)

Number of children in the household

TYPE OF ASSISTANCE NEEDED

Please, in the box below, tell us what items you are in need of (hygiene, size of diapers, etc.).

NOTE: we are unable to assist with rental assistance, gas vouchers, or pet items
Leaving this field blank will DELAY our ability to assist you.

REQUIRED! Please be specific.

REQUIRED DOCUMENTS

Due to abuse of our family assistance program, we now require the submission of a valid driver's license or state-issued ID, as well as CURRENT proof of address. We reserve the right to deny any application that violates our "one person per household" rule.

Picture of Driver's License or ID

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Proof of address (utility bill, car registration, etc.)

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TERMS & CONDITIONS

Safe Harbor Support Center runs on the generosity of our community donations. All supplies/assistance are dependent solely on the availability of our stockroom at the time of your request. We cannot guarantee our ability to provide you with all of your request, but we will assist you to the best of our abilities. Please understand that in order to ensure we can help as many in our community as possible, we are an emergency resource, and have time period limits on how often we are able to assist.

PLEASE, only one person per household.

This will ensure we can help as many households in the community as possible.

"I understand that assistance appointment is NOT guaranteed until I receive a confirmation email from staff. This may take 24-48 business hours. If appointment is approved, I will be assigned a day and time to pick up my care package. If I cannot make it to my scheduled time, I must notify staff as soon as possible via email. If I am a "no show" to my appointment, rescheduling is not guaranteed and my package may be redistributed to another client. I will have to re-apply for assistance in this case. I understand that Safe Harbor may not be able to fulfill all of my request, as family assistance is based on community donations and supply on hand."

I have read and agree to the terms & conditions

REQUEST SUCCESSFULLY SUBMITTED. Appointment is NOT complete/guaranteed until you receive a confirmation email from our staff. Confirmation emails will be sent within 24-48 business hours so please check your email. Thank you!