Aid request form

Heal-Corp is dedicated to supporting households in our community that have been adversely affected by the recent storms. The impact of the storms has severely disrupted many families, particularly their access to clean drinking water, which poses significant health risks.

In response, we are providing water purification systems free of charge to those most in need. These systems will ensure that families can access safe, clean drinking water, thereby minimizing the risk of waterborne diseases and enhancing overall health and wellness.

We encourage you to apply for this assistance by completing the attached application form. This form will enable us to identify and reach the households that require this vital service. We believe that this initiative will profoundly benefit those affected by the storms and aid in the broader recovery and resilience of our community.

Name:

Address:

Phone number:
Cell:

Home:

Email Address:

Number of Household Members:

Brief Description of the Impact of the Storm on Your Household:

Are you currently displaced or living in temporary housing? Specify:

Do you have running water? If yes, are there restrictions/guidelines from the Department of Health?

Do you have access to well water, river water, or other sources? Please Specify:

Why do you need the water purification system?

What size water tap do you have?

Do you have electricity?

Are you planning to leave the area at any time?

Do you need relocation services?

Have you received any assistance from other NGOs or the government?

Are you currently employed?

Do you or your family members have special health needs?

Thank you for taking the time to fill out this application. We are here to assist you and are more than willing to answer any questions you may have. We look forward to supporting you during this challenging period.