MEDICAL, DENTAL, MENTAL HEALTH, AND OTHER

Thank you for making this request on behalf of a community member in need. Please complete the
following form to ensure that we have all the information we need in order to make a timely decision on
your request. Thank you!

NOTE: Requests cannot be accepted directly from the individual in need. This form must be submitted by a community validator who will represent the person or family for this transaction. Please click here for more details.

Validator Information

Validator Name : *

Validator Email: *

Validators organization or connection to the person in need: *

The City or Town Where Person Lives: *

(Please click here for links to other Womenaid groups.)

Has the person been helped by Womenaid in the past 12 months? *

YES NO

If YES, how much was the amount contributed by Womemaid, when, and for what reason? *

The exact amount of money NEEDED : *

The exact amount REQUESTED : *

MEDICAL, DENTAL, MENTAL HEALTH & OTHER.

Please select the type of assistance you are requesting: *

Please give us some background information on the situation at hand: *

Other Needs

Please select the type of assistance you are requesting: *

Please provide some brief background information on the situation at hand. *

The Resources Contacted for Assistance

Please list all the other resources and avenues of assistance that have been contacted relative to this re-
quest. This avoids duplication of services and appropriately places Womenaid of Greater Portsmouth in its correct position of being “the last resort” or “the last piece of the puzzle” in providing assistance. Resources contacted and reasons, if any, for refusal.

Resources Contacted for Assistance *

Payment

Vendor To Be Paid: *

Contact Name for Vendor to be Paid: *

Mailing Address for USPS Mailing of a Check : *

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City

State

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MEDICAL, DENTAL, MENTAL HEALTH& OTHER

Validator Information

MEDICAL, DENTAL, MENTAL HEALTH & OTHER.

Other Needs

The Resources Contacted for Assistance

Payment

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MEDICAL, DENTAL, MENTAL HEALTH
& OTHER