FAMILY HEALTH GARDEN
EMERGENCY ASSISTANCE REQUEST

URGENT - Complete for immediate assistance

Contact Information:
- Full Name: ____________________
- Phone Number: ________________
- Email Address: ________________
- Current Address: _______________

Emergency Situation:
□ Food Emergency
□ Shelter/Housing Crisis
□ Utility Shutoff Notice
□ Medical Emergency
□ Transportation Emergency
□ Other: _______________________

Description of Emergency:
_________________________________
_________________________________

Immediate Needs:
_________________________________

Timeline: How urgent is this request?
□ Within 24 hours
□ Within 3 days
□ Within 1 week

Previous FamilyHealthGarden Services:
□ Yes □ No

If yes, when: ____________________

Signature: _____________________ Date: _________

Submit immediately to: emergency@familyhealthgarden.com
Emergency Hotline: (800) HELP-FAM