Application for Assistance – Dev Page All areas with an asterisk (*) must be filled out. "*" indicates required fields Select One* I am requesting help for myself I am a family member I am a caregiver I am a medical professional Referrer InformationReferrer First Name* Referrer Last Name* Referrer Email Address* Referrer PhoneIs it OK to contact the applicant?* Yes No Applicant InformationFirst Name* Last Name* Date of Birth* Gender* Male Female Other Race* Hispanic or Latino Not Hispanic or Latino White Black or African American American Indian or Alaskan Native Asian Native Hawaiian or other Pacific Islander Race/Ethnicity Unknown Address* Address 2 City* SOAR assistance is limited to residents of Frederick County, MarylandZip Code* Email Address Phone*Married* Yes No Spousal InformationSpouse's First Name* Spouse's Last Name* Spouse's Date of Birth* Spouse's Email Address Spouse's Phone*Economic InformationHousing Situation* Homeowner Rents Home Lives with Family/Friend Homeless Monthly Income* Asset Level*Savings Account/CD/Pensions/Annuities. Do NOT include home or car.Asset Amount* Do you own a working vehicle?* Yes No Are you able to drive?* Yes No Currently receiving assistance from* None SNAP/Food Stamps Energy Assistance Dept. of Social Services/Senior Care Program Meals on Wheels Partners In Care Veterans Administration Religious Coalition Salvation Army Golden Care Other Other Assistance* Veteran or spouse of a veteran?* Yes No Has the applicant requested assistance with us in the past?* Yes No Type of Assistance Requested* Mortgage/Rent Utilities Food Medical bills Medical Equipment Transportation Other Other Assistance Requested* More Information*Please explain your situation in detail to help us better understand how to serve you. Specifically, please include what your needs are, i.e., food, transportation, medications, medical equipment, household needs, etc.SOAR InformationHow did you hear about us?*Do we have permission to speak to other agencies/organizations/providers on your/applicants behalf?* Yes No Would you be willing to share your story, a photo, and/or participate in an interview for how SOAR assisted you?* Yes No By submitting this request for assistance, I affirm that the facts set forth in it are true and complete. I understand that if accepted as a recipient of assistance, my false statements, omissions, or other misrepresentations made by me on this application may result in future loss of assistance from SOAR. It is the policy of SOAR, Supporting Older Adults through Resources, Inc. to provide equal opportunities without regard to race, religion, national origin, gender, sexual orientation, age, or disability.CommentsThis field is for validation purposes and should be left unchanged.
