Please fill out the form below and press the “Submit Application” button when completed.

‘ONE CAN HELP’ ASSISTANCE APPLICATION

This form should be completed on-line only. Please note that this organization is staffed completely by volunteers. If you do not hear from us within 5 business days, please call 617 930-3468.

1. What type of help are you requesting?

2. Describe how this item or service helps your client. (Within the rules of confidentiality, please be as specific a possible while describing the issues facing your client.)

3. Please describe what other attempts have been made to secure this item or service.

4. The following information is required before we can facilitate your request:
(All details regarding the specific item or service must be provided because we are unable to find items or services for your client. We just try to help pay for them.)

Approximate cost of this item / service:
Name of the vendor:
Name and telephone number of the vendor contact person:
Date this assistance is needed by (if known):

 

5. Include all additional information that might expedite your request:

6. So that we may contact you promptly, please provide the following.

Your name:
Your relationship to the client (ie. social worker or attorney):
Your E-mail address:
Your most direct telephone numbers:

 

7. By submitting this form, I acknowledge that I will be expected to help arrange the item / service for my client since I understand that no money will be given to clients directly. (check box)  

8. I also agree that if this request is approved, I will be willing to discuss what impact (if any) this service had for my client, at a future date, with a 'One Can Help' staff member. (check box)  

    

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