Senior Assistance Request Form

Washington Borough Senior Assistance Request Form

Name:	(Required)
Street Address:
City: State: Zip:
Telephone:	(Required)
E-Mail Address:	(Required)
Subject:
Emergency contact name/phone

I/we need assistance with (check all that apply):
taking my trash out taking my recyclables out snow removal raking leaves

I/we would like boro officials to (check all that apply)
Contact volunteers and give them my/our information on my behalf
Provide me/us with the contact information and I/we will call those willing to assist
I/we cannot afford to pay for assistance, but am willing to accept volunteers assisting me
I/we am willing to pay someone to assist me
Inform the office of emergency management that I/we have a physical disability
Inform the office of emergency management that I/we am housebound and to remember me in the event of power outage or major event

Other::