Emergency Assistance 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.
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.
(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.)