Community Resource Request Intake Form

Community Resource Request Intake Form — Form Fields

This nonprofit template includes 9 fields. Allow community members to request resources such as food, clothing, housing referrals, or financial assistance. Free to customize and use on ZenBuild.

• Full Name (text, required)
• Phone Number (text, required)
• City and ZIP Code (text, required)
• Type of Assistance Needed (dropdown selection, required) — options: Food, Clothing, Housing Referral, Utility Assistance, Transportation, Medical Referral, Financial Assistance, Other
• Please describe your situation and what you need (long text, required)
• Number of People in Household (number, required)
• How did you hear about us? (dropdown selection, optional) — options: Referral, Social Media, Search Engine, Community Flyer, Friend or Family
• Is this an emergency situation? (multiple choice, required) — options: Yes, No
• Any additional information (long text, optional)