If you are human, leave this field blank.211 Emergency RequestPlease complete the entire form- your request cannot be processed without all information! We will call you when your order is ready for pickup. As always, this program is confidential and private. If you are uncomfortable providing any identifying information on this form, you may contact the main office directly at 508-435-6511 or [email protected]. Please note that you must show a legal form of identification for all individuals applying. Project Just Because does not have or provide gift cards, pay rent or mortgages, and does not pay bills to our 211 system.Name *AddressApt, suite, etc.CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeEmail *Phone *Who Referred You?How did you hear about us? 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 NameShelter Contact Information Additional InformationThe 211 Emergency program provides necessities such as clothing, shoes, bedding and housewares to help people in crisis get back on their feet. If you are fleeing a domestic abuse situation, have been the victim of a natural disaster and house fire, are transitioning from homelessness or incarceration, or have recently immigrated to Massachusetts as a refugee, please list all items needed in the form below. We will do our utmost to meet as many of your requests as possible. If you do not meet any of the criteria above but are still in need of necessities, please utilize our other programs including the Free Clothing Store.CheckboxI am applying for the 211 Emergency program because I am experiencing a crisis situation as described above.Please describe your situation *How many adults need items? *01234How many children need items? *0123456Total number of people in your household * Adult #1---Adult 1--- Gender *FemaleMaleNonbinarySizing SpecificationsWomen: 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 *FemaleMaleNonbinarySizing SpecificationsWomen: 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 *FemaleMaleNonbinarySizing SpecificationsWomen: 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 *FemaleMaleNonbinarySizing SpecificationsWomen: 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 *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * Child #2---Child 2--- Gender *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * Child #3---Child 3--- Gender *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * Child #4---Child 4--- Gender *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * Child #5---Child 5--- Gender *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * Child #6---Child 6--- Gender *FemaleMaleNonbinaryDate of Birth *Age *Sizing SpecificationsPlease specify exact sizes. For example: child shirt size 8, child pant size 10. Items Requested * SubmitPlease add [email protected] to your safe senders list in your email account to ensure delivery of your request receipt. If you do not receive your email confirmation, please check your SPAM folder.Captcha *For security verification, please enter any random two digit number. For example: 34Notes/CommentsSubmit
