Resilient Provisions Inc
This form is a confidential and secure way to request support from Resilient Provisions, Inc. for our Adopt a Family Holiday Program, running November–December. The information you provide will only be used by our trusted team to coordinate assistance for you and your family. Your privacy and dignity are our top priorities.
Please note: Submitting this form does not guarantee that your household will receive assistance. Support will be provided based on available resources and donations during the November–December season.
We encourage you to fill out this form to the best of your ability. If you are unable to answer a question, you may leave it blank or write N/A.
Name (First name or an alias is perfectly fine):
Preferred Method of Contact:
Phone CallText Message OnlyEmail
Contact Details (Phone Number or Email Address):
Specific Contact Instructions (Optional):
Number of Adults (18+) in your household:
Number of Children (under 18) in your household:
Ages of Children:
Do you have any pets that need food?
YesNo
If yes, what kind and how many?
Type of Assistance Needed (check all that apply):
Non-perishable foodFresh foodBaby suppliesFeminine hygiene productsGeneral toiletriesHousehold cleaning suppliesOther
If baby supplies needed, please specify formula type and diaper size:
Food allergies or dietary restrictions:
Anything else you urgently need or would like us to know:
How would you prefer to receive your items?
Personalized Drop-OffAnonymous Pick-Up
If you selected Personalized Drop-Off, please provide your full delivery address:
Delivery Instructions (crucial for successful drop-off):
I understand that this information will be kept confidential and used solely by Resilient Provisions, Inc. for coordinating assistance. I confirm that the information I have provided is accurate to the best of my knowledge.
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