COVID-19 Emergency Assistance Form Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code*ZIP / Postal CodeCountry*United StatesEgyptJordanLebanonPalestineYemenCountryBirthdate*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Email* Phone*Phone*How many Individuals in your Household areUnder 18 years old*Ages 19 - 59*Ages 60+*Have you received any assistance either by the Government or an NGO?*YesNoPlease list the name of the organization(s) that provided assistance*Has anyone in your house been affected by the COVID-19 outbreak?*YesNoHave you been laid off or are out of work?*YesNoWere you referred by any of the below organizationsAkkarouna FoundationHelen for Assistance and Human Resources DevelopmentMisr El-KheirPalestinian Organization for Development (POD)Relief & Crisis Management Org (SOS)Were you referred by any of the below organizations?*Akkarouna FoundationHelen for Assistance and Human Resources DevelopmentMisr El-KheirPalestinian Organization for Development (POD)Relief & Crisis Management Org (SOS)CommentsPlease upload a copy of a past-due bill Drop files here or Accepted file types: jpeg, jpg, png, pdf. Allowed file extensions: .jpg, .jpeg, .png, .pdf | Maximum File Size: 3 MBCAPTCHAConsent* I authorize UMR to collect the information collected by the form for relief related activities Our Partners on the Ground Previous Next