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Community Choice Material Aid Request

This form is to specifically request Material Aid support from the JUNK group.

This form is to be completed by partner agencies supporting the delivery of the Community Choice initiative with the distribution of our program to community members accessing assistance through their services.

It is NOT intended that any questions contained within this form be used as an interview script OR specifically asked of community members accessing assistance through the initiative. We simply ask that partner agencies provide information to the best of their knowledge and ability to assist us in providing suitable support to participants.

Completion of this form should ONLY be done by staff/volunteers of partner agencies supporting the delivery of the initiative.

All data collected within this form related to the community member is confidential and will not be shared beyond. Contact details for community members are only used to assist the JUNK group in the delivery of their services and will not be used by any other agency (including the Give Where You Live Foundation). De-identified data related to gender, age group, household size, cohort and challenges will only be used as per the agreed purposes contained within the partner agreement.

Community Aid Request

SECTION 1: Agency Information

Name of Agency Representative
Name of Agency Representative
First
Last
Are you completing this form for another staff member / caseworker? Please provide their details below for the JUNK Community House 2 Home Program to contact if needed.

SECTION 2: Beneficiary Information

Participant Information contact details will only be stored and used by the JUNK Community House 2 Home Program for the purposes of providing material aid support. If the clients name is not used, a nominated contact is important for delivery purposes, please make note in details of form if this is the case.
Client Name (or nominated contact for delivery purposes)
Client Name (or nominated contact for delivery purposes)
First
Last
Address
Address
Suburb
State/Province
Zip/Postal
What are the challenges or reason that have led to this person seeking help?

SECTION 3: Material Aid Request

Please provide details of budget and how many of each items are needed for the individuals listed above.
A$
IncludesL plates, cutlery, bowls, cups, pots, utensils

The following items may be limited and requests may have to go on a wait list

Whitegoods

SECTION 4: Do you require delivery of items?

The JUNK Community House 2 Home Program regularly delivers across Victoria (Metro & Regional). Fees do apply and will be included within the budget provided and will be confirmed with the Junk group staff who may be able to reduce costs based on other deliveries to the area at that time.
Delivery Required
Once completed please click the submit button. Please note that when this form is submitted, your Agency key contact person and the Junk group will receive a copy of this form immediately.

If you have any questions for the Junk group staff, please contact Shamus on [email protected] or phone 13 44 55

Call 13 44 55
Call 13 44 55
Enquiry Now
Enquiry Now