Community Fund Financial Support Request Form

The following questions will help us assess what support will be the right fit for you and your household/family. If you have any questions or need assistance completing the form, please contact our Front Desk at 503-284-3377, or email programs@necommunitycenter.org

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* 1. What is your name?

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* 2. What are your pronouns (e.g., she/her, he/him, they/them, etc)

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* 3. What is your Date of Birth?

Birthdate

Date

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* 4. Please provide us with the following information (if you do not currently have a stable address or do not use email, enter N/A).

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 5. Would you prefer we contact you by phone or email?

Phone Call

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* 6. Is it okay to leave a detailed message?

Yes

Language Preferences. Please help us understand how to best communicate with you. If you need language or interpretation assistance in Spanish, we will connect you with our Spanish-speaking staff. If you need interpretation assistance in another language, please let us know and we will try to accommodate you.

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* 7. What is your preferred language?

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* 8. Do you feel you can communicate with NECC Staff about programs and activities in English?

Yes

Other (please provide more information, as needed)

Participant Information. Community Fund support applies to everyone in your household who will participate in NECC programs and activities.

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* 9. Community Fund support applies to everyone in your household. Who are you applying for?

Myself Only

Other Household Members

Myself and Other Household Members