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

We kindly request that individuals use our facility for its programs and equipment, not just for showering.

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* 1. First and Last Name (this field is required)

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

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* 3. What is your Date of Birth? (this field is required)

Birthdate

Date

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

Address

City/Town

State/Province

ZIP/Postal Code

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* 5. Please provide us with your contact information.

Phone Number and/or Email address is required to receive a membership and/or participate in programming

Email Address

Phone Number

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

Phone Call

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* 7. 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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* 8. What is your preferred language?

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

This field is required. We are unable to provide financial support for applicants who do not provide this information.

Myself Only

Other Household Members

Myself and Other Household Members

Community Fund Financial Support Request Form

Question Title

* 1. First and Last Name (this field is required)

Question Title

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

Question Title

* 3. What is your Date of Birth? (this field is required)

Question Title

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

Question Title

* 5. Please provide us with your contact information. *Phone Number and/or Email address is required to receive a membership and/or participate in programming*

Question Title

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

Question Title

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

Question Title

* 8. What is your preferred language?

Question Title

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

Question Title

* 10. Community Fund support applies to everyone in your household. Who are you applying for?*This field is required. We are unable to provide financial support for applicants who do not provide this information.*

* 5. Please provide us with your contact information.

Phone Number and/or Email address is required to receive a membership and/or participate in programming

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

This field is required. We are unable to provide financial support for applicants who do not provide this information.