Puerto Rico Relief Form

Name *

First Name

Last Name

Type of Help Requested *

Home Repair

Need Power

Water Filter(s)

Major House Repair

Minor House Repairs

Heavy Mold Removal

Ages of House Occupants *

Infant - 5 years old

5 years old - 11 years old

18 years old to 55 years old

55 - 65 years old

65 years old and up.

How many total occupants in household?

One

2 - 5

5 and up

Enter your Full Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Will you be able to pick items up from San Juan? *

Yes

No