Help from Womenade

1. Your name and contact information (including phone number) as the validator.*
   

   Name
   Street
   Town	State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming ZIP
   Phone	Email

2. The town where the person in need resides:*
3. The exact amount being requested:
4. A brief description of the need for assistance:*
   
5. A brief explanation of other resources being used or pursued, including local city/town welfare [If this is a request for a utility payment, please note whether you have contacted the local Community Action program to determine your client's eligibility for federal and local utility assistance programs.]
   
6. Oyster River Womenade is a small, local non-profit capable of providing only a limited amount of assistance. Do you anticipate that this will be a one-time need, or an ongoing concern?
   One-time Ongoing
7. The name and address of the vendor which will be paid (please include account numbers/residence address, if applicable):
   
8. Will your client allow us to share their story with others, anonymously, at fund raising events and on our blog?
   Yes No

Fields marked with a * are mandatory.