Request Support

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Request Support

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Request Support

Request for Support

"*" indicates required fields

Step 1 of 4

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This field is for validation purposes and should be left unchanged.

Date of Request*

MM slash DD slash YYYY

Your Name*

First Last

Your Email*

Enter Email Confirm Email

Your Phone Number*

How can we help?*

I am requesting support for myself

I am requesting support for someone else

Details of Individual in Need

Name of Individual in Need*

First Last

Date of Birth*

MM slash DD slash YYYY

If under 18 years of age, we can't process the request.

Social Security #*

Provide the last 4-digits of Social Security number.

Location of Individual in need*

Street Address Address Line 2 City State ZIP Code

Type of Support

Please note: Request cannot exceed $1,500.00.

Amount Requesting*

Type of Support Requested*

Housing Assistance (e.g. rent, eviction avoidance, new deposit for rental)

Utility Assistance (e.g. water bill, electric bill, gas bill)

Medical Bills (e.g. paying ER bill, paying dental bill)

Medical Supplies (e.g. wheelchair, cane)

Other

Please Provide the Information Below

Type of Assistance*

Landlord Name*

First Last

Mortgage Company Name*

Billing Entity Name*

Email*

Enter Email Confirm Email

Phone*

Do you use a payment portal*

Yes

Upload a copy of your lease*

Max. file size: 1 GB.

Upload a copy of your mortgage statement*

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Billing Entity Email*

Enter Email Confirm Email

Billing Entity Phone*

Upload a copy of your invoice*

Max. file size: 1 GB.

Upload a copy of your medical bill*

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Name of Medical Supply*

Describe the Supply Needed*

Upload an image of the item*

Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB.

Additional Information

Please provide a detailed description of the support needed, including the circumstances that led to the need for financial assistance as well as how you plan to pay future costs if you receive this one-time financial assistance.*

Has the person in need applied for any of the below:*

Check all that apply.

Rental Assistance

Public Rental Assistance

Medical Insurance Claim

Other Community Resources

None of the above

File Upload

Upload a copy of the image/receipt*

Max. file size: 1 GB.

Please see file types needed for each request type

Housing Assistance

Current billing statement, lease agreement, or eviction notice

Utility Assistance

Current utility billing statement

Medical Bills

copy of invoice and/or document outlining how much insurance will cover

Medical Supplies

copy of invoice and/or document outlining how much insurance will cover

Items for Purchase

list of specific items with cost and link to online retailer (Screenshots and/or link to online wishlist preferred)

All donation payments are made via credit card. Unfortunately, we cannot process rent with cash, wire transfers, money orders, Zelle, PayPal, Venmo.*

I have confirmed this donation can be paid with a credit card.

Media Release

If selected to receive a grant from Shoulder to Shoulder, the requestor and individual in need agree to grant permission to Shoulder to Shoulder, hereinafter known as the “Media” to use their image (photographs and/or video) for use in Media publications including:

Videos & Pictures
Email Blasts
Newsletters
All S2S Social Media Platforms and/or Social Media Affiliates
S2S Website and/or Affiliates

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

Please check the paragraph below which is applicable to your present situation:

I Agree*

I am 20 years of age or older and I am competent to contract in my own name/have my care specialist or anyone submitting this application on my behalf. I have read or have had this release read to me before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

I Agree*

I Decline*

I decline the use of my image (photographs and/or video) for use in any Shoulder to Shoulder media, newsletters, social media platforms and websites.

I Decline*

How did you hear about us?*

Upward Health Care Team

Social media

Website

Family or friend

Other

CAPTCHA

Grant Request Process

S2S strives to make access to funds accessible and uncomplicated. The grant making process follows these simple steps:

Fill out the “Request for Support” form
Submit the form
The request will be shared with the S2S review committee
The committee will meet to review the request and approve/deny the request
The decision will be communicated to the requestor via email
If the request is approved, the foundation will reach out directly to the requestor to assist in the distribution of funds
S2S supports one time donations for individuals in need. (We are unable to process recurring payments for the same household.)

info@shouldertoshoulderfoundation.org

80 Arkay Drive, Suite 230
Hauppauge, NY 11788

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Shoulder to Shoulder Foundation is a 501(c)3 nonprofit organization.

TAX ID#: 85-4393233

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