Emergency Assistance Intake Form

We know asking for help can be difficult, and we're here to support you with compassion and respect. Please fill out this form so we can best understand your needs and assist you as quickly as possible. School departments may apply for emergency assistance on behalf of families, with the family's knowledge and consent, to help ensure timely support and access to resources.

This application is for short-term emergency financial or material assistance for families with minor or school-aged children living in the household. Support is available to those experiencing urgent crises—such as eviction, utility shutoff, fire, domestic violence, or medical emergencies—and residing in Attleboro, Dighton, Mansfield, North Attleboro, Norton, Plainville, Rehoboth, Seekonk, or surrounding service areas.

Person Completing this Form

Select one

Are you filling this out on your own behalf?

Are you filling this out on behalf of a family who needs assistance?

Your Name

First Name

Last Name

Person in Need of Support

Name

First Name

Last Name

Phone Number

Current Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Emergency

YYYY

Address Where Emergency Took Place

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Have you or your family recently had to leave your home due to a crisis?

Yes

Brief Description of Emergency

# of People in Household

Names & Ages of Household Members

Special Needs Dependents? If yes, explain

Brief Description of Assistance Requested

Review Process

The Executive Director reviews each application and if eligible, submits a recommendation to the Board of Directors. The Board then reviews and votes on the request within 2–3 business days. Whenever possible, approved assistance is paid directly to vendors such as landlords or utility providers. All decisions are made at the sole discretion of the Council, based on demonstrated need, available resources, and adherence to established policy.

Emergency Assistance Intake Form

Thank you for Your Support!