211 Emergency/Domestic Abuse Request

After a domestic abuse incident, house fire, or natural disaster, Project Just Because helps families get back on their feet by providing basic necessities. This may include toiletries, clothes, other supplies, and access to our furniture network. We keep very special comfort items just for kids when they come out of their home and go into a safe house.

As always, this program is confidential and private.

If you need help recovering from a domestic abuse situation or other household emergency, please complete the form below. We can only provide you with items you have requested if we have them in stock.

Name *

Address *

Country

City

Zip code

Email *

Phone *

Shelter/Safe House

If you currently live in a shelter or safe house, please list the name and contact info for the shelter/safe house.

Shelter Contact Name

Shelter Phone

Additional Information

Please describe your situation *

How many adults need items? *

How many children need items? *

Total number of people in your household *

Adult #1

---Adult 1--- Gender *

Female

Male

Sizing Specifications

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Items Requested *

Adult #2

---Adult 2--- Gender *

Female

Male

Sizing Specifications

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Items Requested *

Adult #3

---Adult 3--- Gender *

Female

Male

Sizing Specifications

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Items Requested *

Adult #4

---Adult 4--- Gender *

Female

Male

Sizing Specifications

Women: please use a number size when possible. For example: “women’s 10”
Men: please specify waist x length for pants. For example: “men’s pants 36×30”

Items Requested *

Child #1

---Child 1--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Child #2

---Child 2--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Child #3

---Child 3--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Child #4

---Child 4--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Child #5

---Child 5--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Child #6

---Child 6--- Gender *

Female

Male

Date of Birth *

Sizing Specifications

Please specify exact sizes. For example: child shirt size 8, child pant size 10.

Items Requested *

Demographic Information (optional)

This information is used for funding purposes only! Your answers will not impact the fulling of your order in any way (even if you choose not to complete it). The information gathered may help Project Just Because to receive grants to further benefit those in need. Thank you!

Ethinicty - Other

If you selected "other", please describe how you identify your ethnicity.

Are you a veteran?

Yes

Submit

Captcha *

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Notes/Comments