Heart(h) for Homes

Are you requesting help for yourself or nominating someone else? *

I am requesting help for my householdI am nominating another household

Your Name *

Your Email Address *

Your Phone Number *

Name of the Person or Household Needing Assistance

If you are applying for yourself, you may leave this blank.

Community *

Please select a communityClearwaterVavenbyBlackpoolBirch IslandLittle FortOther nearby community

If you selected another community, please tell us where:

Is firewood the household’s primary or essential source of heat? *

YesNoPartially

Approximately how much usable firewood remains? *

Please select oneLess than one weekOne to two weeksThree to four weeksMore than one monthCurrently out of firewoodUnsure

How much assistance is being requested? *

Please select oneOne full cordA partial cord would helpAny amount available would helpUnsure

Please select any circumstances that apply:

Senior householdPerson with a disabilityLow-income householdSerious illness or medical hardshipUnexpected financial or personal crisisChildren living in the householdLimited access to transportationNo other source of firewood assistancePrefer not to say

Does the household require delivery? *

YesNoUnsure

Would assistance with stacking be needed? *

YesNoUnsure

Can the property be safely accessed by a pickup truck or delivery vehicle? *

YesNoUnsure

Please briefly tell us about the household’s circumstances and why assistance is needed:

Is there anything else we should know about delivery, accessibility or urgency?

I confirm that the information provided is accurate to the best of my knowledge. If I am nominating someone else, I have their permission to share their contact information and for Hearth & Hive Community Society to contact them.

I understand that submitting this form does not guarantee assistance. I consent to Hearth & Hive Community Society using this information to assess this request and coordinate the Heart(h) for Homes campaign. Personal information will be kept private and will not be shared publicly without permission.

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