The Lyndon Family Fund aims to provide assistance to local Lyndon families in need of additional support with children under the age of six. Lyndon Family Fund Fill out the form below to request assistance. Families can receive a MAX of 3 awards, but may apply as many times as desired.1. Tell us what we can help you withWhat do you need funds for?*Gas CardMoney for GroceriesSporting EquipmentAmount Requested*Presenting Issue/Request/Need*2. Tell Us about you & your family.Full Name* First Name Last Name Birth Date* Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Best time to contact you:MorningsAfternoonsEveningsList all your household membersFamily Member 1 First Last AgeFamily Member 2 First Last AgeFamily Member 3 First Last AgeFamily Member 4 First Last Age3. What other resources do you use?Please check all resources you or someone in your household has used in the past 60 day:Immediate Needs: H.O.P.E Umbrella Mental Health Services Housing: NEKCA Intake Worker Applied for GA / Emergency Assistance at ES Economic Services (ES) Eligibility Worker Reach-Up Worker Youth Services IL Program NCMC / Section 8 Other Fuel/Utilities Fuel Assistance Emergency Fuel Assistance Contact with Utility for payment plan Other Food Applied for Food Stamps / WIC Given a list of Food Shelf & Free Meals School Lunch Programs Given list of Senior Meal Sites Other Other: Family Support Childcare Ecumenical Council Other Please briefly explain the instances on the previous page.What assistance you applied for? Were you approved/ denied? What amount was given?* I certify that the above information is accurate and complete to the best of my abilities and knowledge. * I acknowledge that the information provided above will be shared and reviewed by the Lyndon Promise Community Steering Committee, which includes local Community Partners and organizations. It will only be shared as necessary in regards to this application. A message can be left at the above phone number on voicemail or with person answering the phone. I want to be referred to other services if applicable. A community partner assisted me in completing this application. The above community partner personnel, _______________________, may be contacted regarding my application, including clarification, current status, and the outcome of this application. Community Partner NameApplication AgreementSignature*By entering your full name above you're providing a digital signature on this application and by clicking submit, you agree to our Terms and Conditions.NameThis field is for validation purposes and should be left unchanged.