UCAN :: Additional help

Which county do you live in?*

Douglas County

Josephine County

First Name*

Last Name*

Physical Address (please include your street number, street name, and, if you rent an apartment, apartment number)*

City*

Zip Code*

Mailing Address (if different from physical address)

City (where you receive mail)

Zip Code (where you recive mail)

Email address (if you have more than one, please provide the one that you use most often)

Cell phone number

Other phone number (if you don't have a cell phone)

How would you like us to contact you?*

Phone

Text

Email

Have you been impacted by the COVID-19 crisis?*

Yes

No

Number of people in the household*

Income* $

per

Week

Month

Year

Do you currently have health insurance?*

Yes

No

Please select the type of help you need. You may choose more than one type of help.*

Rent

Utility payments

Health insurance

If you have more information you want to share with us, please type it here: