Emergency Assistance

Emergency Assistance Application

Please note that this program is to be used exclusively for civil disasters. If you are need of assistance with a life-threatening or terminal illness, please click here.

Download Application

Online Application

Please fill in as many fields as possible and click the SUBMIT button at the bottom of the page. All information is confidential and will be used for Take The Lead purposes only.

(Note that information entered into this form is protected by a secure Internet connection using 128 bit encryption to protect the privacy and security of your information.)

Online Application Form

Step 1 of 4

Personal
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Social Security Number
Date of Birth*
Please describe your specific needs*

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Emergency Assistance