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Intake form
Help us serve you better
Name
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Email address
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What is your age group?
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Under 18
18-24
25-34
35-44
45-54
55-64
65 and over
Do you have any physical disabilities?
Please select at least one option.
Mobility impairment
Vision impairment
Hearing impairment
Cognitive impairment
No disabilities
Are you a veteran?
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Yes
No
What type of assistance are you seeking?
Please select at least one option.
Food assistance
Community gardening
Financial assistance
Volunteer opportunities
How did you hear about hardtimez foundation?
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Social media
Friend or family
Community event
Website
Which service or services are you interested in?
Please select at least one option.
Community gardening
Monthly allowances
Fundraising events
Additional questions or comments
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