Form Center

2. First Name*
3. Last Name*
5. Address*
7. City
8. State
9. Zip Code
11. Phone Number*
12. Email Address
14. Please select the reason for needing assistance*

    1. Have a physical disability
    2. Am over the age of 60 and need assistance
    3. Am otherwise physically unable to shovel
    4. Other
15. If "other" please explain

    This information will not be shared and will only be used by staff to determine need.

17. Please explain if your need will be ongoing or if you only need assistance on a specific date. *
Leave This Blank:


19. 1. Receive an email copy of this form.
20. Email address

    This field is not part of the form submission.

21. Submit

* indicates a required field